Differential Diagnosis for Skin Conditions

Differential Diagnosis for Skin Conditions

Differential Diagnosis for Skin Conditions

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

ORDER NOW FOR COMPREHENSIVE, PLAGIARISM-FREE PAPERS

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.

Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?

Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.

Consider which of the conditions is most likely to be the correct diagnosis, and why.

Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.

Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.

Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

The Lab Assignment

Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

REQUIRED READINGS

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 9, “Skin, Hair, and Nails”

This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

This section explains the procedural knowledge needed prior to performing various dermatological procedures.

Chapter 1, “Punch Biopsy”

Chapter 2, “Skin Biopsy”

Chapter 10, “Nail Removal”

Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”

Chapter 16, “Skin Tag (Acrochordon) Removal”

Chapter 22, “Suture Insertion”

Chapter 24, “Suture Removal”

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 28, “Rashes and Skin Lesions”

This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.

Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)

VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals

This interactive website allows you to explore skin conditions according to age, gender, and area of the body.

Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282.

This document contains five images of different skin conditions. You will use this information in this week’s Discussion.

Document: Comprehensive SOAP Exemplar (Word document)

  • attachment

    DifferentialSkinDiagnosis.doc

    Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions

    1: image1.jpg

    2: image2.jpg

    3. image3.jpg

    4. image4.jpg

    5.

    image5.jpg

    �Note to Build: These images are still pending permissions so I don’t have credit lines yet or approval.

     

    Page 5 of 5

  • attachment

    ComprehensiveSOAPEx.docx

    Comprehensive SOAP Exemplar

     

    Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

     

    Patient Initials: _______ Age: _______ Gender: _______

     

    SUBJECTIVE DATA:

     

    Chief Complaint (CC): Coughing up phlegm and fever

     

    History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Differential Diagnosis for Skin Conditions

     

    Medications:

    1.) Lisinopril 10mg daily

    2.) Combivent 2 puffs every 6 hours as needed

    3.) Serovent daily

    4.) Salmeterol daily

    5.) Over the counter Ibuprofen 200mg -2 PO as needed

    6.) Over the counter Benefiber

    7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

     

    Allergies:

    Sulfa drugs – rash

     

    Past Medical History (PMH):

    1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.

    2.) Hypertension – well controlled

    3.) Gastroesophageal reflux (GERD) – quiet on no medication

    4.) Osteopenia

    5.) Allergic rhinitis

     

    Past Surgical History (PSH):

    1.) Cholecystectomy 1994

    2.) Total abdominal hysterectomy (TAH) 1998

     

    Sexual/Reproductive History:

    Heterosexual

    G1P1A0

    Non-menstrating – TAH 1998

     

    Personal/Social History:

    She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

     

    Immunization History:

    Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

     

    Significant Family History:

    Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.

     

    Lifestyle:

    She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.

     

    She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

     

    Review of Systems:

     

    General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

     

    HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

    Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

     

    Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.

     

    Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

     

    CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

     

    GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

     

    GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.

     

    MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

     

    Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.

     

    Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

     

    Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

     

    Endocrine: no endocrine symptoms or hormone therapies.

     

    Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

     

     

    OBJECTIVE DATA

     

    Physical Exam:

    Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

    General: A&O x3, NAD, appears mildly uncomfortable

    HEENT: PERRLA, EOMI, oronasopharynx is clear

    Neck: Carotids no bruit, jvd or tmegally

    Chest/Lungs: CTA AP&L

    Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

    ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

    Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

    Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

    Neuro: CN II – XII grossly intact, DTR’s intact

    Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

     

    ASSESSMENT:

     

    Lab Tests and Results:

    CBC – WBC 15,000 with + left shift

    SAO2 – 98%

     

    Diagnostics:

    Lab:

    Radiology:

    CXR – cardiomegaly with air trapping and increased AP diameter

    ECG

    Normal sinus rhythm

     

    Differential Diagnosis (DDx):

    1.) Acute Bronchitis

    2.) Pulmonary Embolis

    3.) Lung Cancer

     

    Diagnoses/Client Problems:

     

    1.) COPD

    2.) HTN, controlled

    3.) Tobacco abuse – 40 pack year history

    4.) Allergy to sulfa drugs – rash

    5.) GERD – quiet on no current medication

     

    PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

     

     

    © 2019 Walden University Page 4 of 4

     

    © 2019 Walden University Page 3 of 4

  • attachment

    ComprehensiveSOAPTemplate.docx

    Comprehensive SOAP Template

     

    Patient Initials: _______ Age: _______ Gender: _______

     

    Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

    O = onset of symptom (acute/gradual)

    L= location

    D= duration (recent/chronic)

    C= character

    A= associated symptoms/aggravating factors

    R= relieving factors

    T= treatments previously tried – response? Why discontinued?

    S= severity

     

    SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

     

    Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

     

    History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

    1. Location

    2. Quality

    3. Quantity or severity

    4. Timing, including onset, duration, and frequency

    5. Setting in which it occurs

    6. Factors that have aggravated or relieved the symptom

    7. Associated manifestations

     

    Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

     

    Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

    Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

     

    Past Surgical History (PSH): Include dates, indications, and types of operations.

     

    Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

     

    Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

     

    Immunization History: Include last Tdp, Flu, pneumonia, etc.

     

    Significant Family History: Include history of parents, Grandparents, siblings, and children.

     

    Lifestyle: Include cultural factors, economic factors, safety, and support systems.

     

    Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

     

    General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

    HEENT:

    Neck:

    Breasts:

    Respiratory:

    Cardiovascular/Peripheral Vascular:

    Gastrointestinal:

    Genitourinary:

    Musculoskeletal:

    Psychiatric:

    Neurological:

    Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.

    Hematologic:

    Endocrine:

    Allergic/Immunologic:

     

    OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

     

    Physical Exam:

    Vital signs: Include vital signs, ht, wt, and BMI.

    General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

    HEENT:

    Neck:

    Chest/Lungs: Always include this in your PE.

    Heart/Peripheral Vascular: Always include the heart in your PE.

    Abdomen:

    Genital/Rectal:

    Musculoskeletal:

    Neurological:

    Skin:

     

    ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. Differential Diagnosis for Skin Conditions

     

    PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

     

    Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

     

    Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

     

    Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

     

    REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?

     

     

    © 2019 Walden University Page 2 of 3