Assignment: NURS 6512 Differential Diagnosis for Skin Conditions
Walden University Assignment: NURS 6512 Differential Diagnosis for Skin Conditions-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University Assignment: NURS 6512 Differential Diagnosis for Skin Conditions assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for Assignment: NURS 6512 Differential Diagnosis for Skin Conditions
Whether one passes or fails an academic assignment such as the Walden University Assignment: NURS 6512 Differential Diagnosis for Skin Conditions depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for Assignment: NURS 6512 Differential Diagnosis for Skin Conditions
The introduction for the Walden University Assignment: NURS 6512 Differential Diagnosis for Skin Conditions is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for Assignment: NURS 6512 Differential Diagnosis for Skin Conditions
After the introduction, move into the main part of the Assignment: NURS 6512 Differential Diagnosis for Skin Conditions assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for Assignment: NURS 6512 Differential Diagnosis for Skin Conditions
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for Assignment: NURS 6512 Differential Diagnosis for Skin Conditions
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Sample Answer for Assignment NURS 6512 Differential Diagnosis for Skin Conditions
SUBJECTIVE DATA:
Chief Complaint (CC): “My left thumbnail has been having a vertical split at the center for the last three months”
History of Present Illness (HPI): AD is a 34-year-old white male who presents with a vertical split on his left thumbnail. He states that it started four months ago. He reports he tends to habitually rub the thumb’s nail fold using the tip of the second digit. He also states that he has frequented a manicurist in the last four months who have been pushing back his cuticle during the manicure. His nail has a crack that extends laterally and looks like the branches of a fir tree. He denies erythema or warmth and no other fingernails are affected. The finger is painless.
Medications: None
Allergies: No known drug or food allergies.
Past Medical History (PMH):
- Tonsilitis
- Appendicitis
Past Surgical History (PSH):
- Tonsillectomy
- Appendectomy
Sexual/Reproductive History:
The patient is a heterosexual and he reports no reproductive issues or risky sexual behavior. He is married with one kid. He has no history of STIs.
Personal/Social History:
The patient is a real estate agent who lives with his wife and kid. Patient denies smoking, ETOH, or consuming any illicit substance. He states that he exercises three times a week and maintains a healthy diet.
Health Maintenance:
AD presents annually for a routine physical exam. He reports bloodwork 2 years ago at an annual exam.
Immunization History:
Immunizations up to date and had a flu vaccine two months ago. He had a Tdap in 2018.
Significant Family History:
Father alive 67 HTN, mother alive 60 healthy. He is the only sibling and he reports that his daughter is in good health with no significant health history.
Review of Systems:
General: The patient denies fever or chills, fatigue, or decreased appetite. He denies difficulty sleeping, night sweats, malaise, chills, or unexplained weight changes.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia, or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, and congestion. THROAT: Denies throat or neck pain, hoarseness, or difficulty swallowing.
Respiratory: The patient denies shortness of breath, cough, or hemoptysis.
Cardiovascular/Peripheral Vascular: The patient denies arrhythmia, chest pain, palpitations, heart murmur, or SOB.
Gastrointestinal: The patient denies abdominal pain or discomfort. He denies flatulence, nausea, vomiting, or diarrhea.
Genitourinary: Pt denies hematuria, dysuria, or change in urinary frequency. He denies difficulty starting/stopping a stream of urine or incontinence.
Musculoskeletal: Pt denies edema, weakness, or joint pain of extremities B/L.
Neurological: Denies headache and dizziness, LOC or history of tremors or seizures.
Psychiatric: Pt denies a history of anxiety or depression. He reports no sleep disturbance, delusions, or mental health history. He denied a suicidal/homicidal history.
Skin/hair/nails: The patient denies rash, petechiae, pruritus, or abnormal bruising/bleeding. He complains of a vertical split on his left thumbnail.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Temp: 98.67 °F, Pulse: 85 and regular, BP: 118/79 mm hg left arm, sitting, regular cuff; RR 17 non-labored; Ht- 6’0”, Wt 170 lb, BMI 23.1.
General: AD is a well-groomed White male of well nutritional status who is cooperative and answers questions appropriately. Alert and oriented x 3.
HEENT: Normocephalic/atraumatic. Eyes: PERRLA. Conjunctiva pink with no scleral jaundice. Mouth: Moist mucosa, No lesions, inflammation, or exudate to the oral mucosa, tongue, or gum line. Ears: No lesions, scars, papules or nodules noted on the helix.
Neck: Supple and trachea midline. No thyromegaly
Chest/Lungs: Equal and bilateral chest rise, breathing unlabored with good respiratory effort no accessory muscle use. No tenderness on palpation of sternum, anterior or posterior thorax. resonant percussion over all lobes. Lung sounds clear on inspiration/expiration, anterior and posterior with no rhonchi, crackles, or wheezing with no areas of diminished breath sounds.
Heart/Peripheral Vascular: RRR. S1 and S2 are normal. No murmurs or bruits were noted. Chest non-tender, no visible heaves, and JVO non-elevated.
Abdomen: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
Genital/Rectal: No bladder distention, suprapubic pain, or CVA tenderness.
Musculoskeletal: 2+ radial and dorsalis pulses. No edema, cyanosis, or clubbing was noted. The patient has a full ROM with no pain, swelling, or tenderness.
Neurological: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
Skin/nails: Warm, dry, and intact. The patient has a feathered, central, longitudinal ridge with a fir tree pattern on his left thumb. He has transverse ridges, parallel and angled towards the nail fold. He also has macrolunulae.
ASSESSMENT:
Differential Diagnosis
- Median nail dystrophy- Refers to a split in the midline of the nail that starts from the cuticle. It affects the thumbs mostly and presents with a longitudinal groove in the central portion of the nail plate that starts at the proximal nail fold (Ball et al., 2019). The groove has small grooves that connect to it in an oblique fashion resulting in an inverse “fir-tree” pattern (Khodaee et al., 2020). It is caused by a temporary defect in the matrix that interferes with nail formation. Harsh trauma to the nail and recurrent self-inflicted trauma is the major cause of the disorder. The patient reports habitually rubbing his thumb’s nail fold using his index finger and visiting a manicurist who pushes his cuticle during a manicure. The presentation and the patient’s report confirm the diagnosis.
- Habit-tic deformity– It is also a form of nail dystrophy that is linked to habitual external trauma to the matrix. It affects the thumbs and presents as central depression and transverse, parallel ridging that runs from the nail fold to the distal edge of the nail (Sathyapriya et al., 2020). The transverse depression projects a “washboard” configuration. Some patients also report redness and swelling along the proximal nail fold (Dains et al., 2019). The diagnosis is ruled out because the current patient has a fir-tree pattern rather than transverse parallel ridges.
- Trachyonychia- Refers to rough nails. It can present as either opaque or shiny. In an opaque trachyonychia, the nail plate has longitudinal ridges while the nails appear opaque, rough, and with a “sandpapered” appearance (Sathyapriya et al., 2020). Shiny trachyonychia on other hand has numerous small pits with longitudinal and parallel lines. The nails have a shiny appearance. The disorder affects all the nails. It is ruled out because the patient does not record any presentation that can be said to be sandpapered or shiny.
- Subungual skin tumors- Refers to skin cancer that affects the skin under the nails. It results in brown-black discolorations of the nail bed that occurs as either a streak or irregular pigmentation (Sathyapriya et al., 2020). The discoloration usually progresses to thickening, splitting, or destruction of the nails. It is however accompanied by pain and inflammation. The current patient reports no pain or inflammation neither does he have any pigmentation ruling out the diagnosis.
Primary Diagnosis
- Median nail dystrophy
References
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.
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.
Khodaee, M., Kelley, N., & Newman, S. (2020). Median nail dystrophy. CMAJ, 192(50), E1810-E1810. https://doi.org/10.1503/cmaj.201002
Sathyapriya, B., Chandrakala, B., Heba, A., & AnubharathyV, G. S. (2020). Deformities, Dystrophies, and Discoloration of the Nails. European Journal of Molecular & Clinical Medicine, 7(5), 2020. https://www.ejmcm.com/article_4114_44f01b00119c36ca34c67eea5116ed45.pdf
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.
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.
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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 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.
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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 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.
Sample Answer 2 for Assignment NURS 6512 Differential Diagnosis for Skin Conditions
SUBJECTIVE DATA: “I have indented reddened streaks on my skin that started appearing on the second month when I became pregnant.” “Too many stretch marks on my stomach since being pregnant”
Chief Complaint (CC): Picture #2- I have a concern with the stretch marks on my stomach which first noticed at the end of my first trimester in pregnancy.
History of Present Illness (HPI): Ms Caroline Fisher is a 32 year old female is a gravida 1, para 0 Black American who is pregnant and in her 24 weeks gestational period who came today and complained about the changes she has been noticing on her abdomen that is characterized by streaks of reddened skin which continued to darken as the pregnancy progresses, last menstrual period was 9/21/21. Ms Caroline stated that the stretchmarks are more prominent on the anterior abdominal while few lines run towards the back. Ms Caroline at this time stated that sometimes she feels itchy but denies any pain or any discomfort. Ms Caroline stated that her friends introduced her to an herbal therapy known as cocoa butter which she has been apply but no obvious changes. Ms Caroline is so much concerned about the recent changes to her body and skin and doesn’t feel good about her recent look, Ms Caroline has a believe that she has actually put on weight and that might have worsened the stretchmarks.
Medications:
Patient is on the following medications;
Pregnacare which contains mostly vitamins
400 μg of folic acid prescribed once daily
Iron 600mg Daily
Metformin 500mg twice daily for diabetes
Norvasc 10mg daily for hypertension
Allergies: Allergic to Sulphur medications. No known food allergies.
Past Medical History (PMH): Ms Craoline is a known Type 2 diabetic patient, was last hospitalized in 2020 prior to her recent pregnancy on account of uncontrolled hyperglycemia which was managed and well controlled during the 2 days’ hospitalization before being discharged, patient also has history of borderline hypertension.
Past Surgical History (PSH): Patient denies any surgical history.
Sexual/Reproductive History: Ms. Caroline is Straight and is sexually active. No positive history of sexual abuse, has had 2 partners since she became sexually active. Menarche started at the age of 12 and since then have always had a regular menstrual cycle of 28days.
Personal/Social History: Ms Caroline is an elementary school teacher and lives with the boyfriend in a single family house. Denied history of illegal drug use, drinks alcool occasionally but stopped since she got pregnant.
Health Maintenance: Ms Caroline has been compliant with her regular pregnancy checkup and consults as advised.
Immunization History: Mrs Coroline is upto date with her vaccinations including covid vaccine and the last immunization was the flu shot which she got on 1/3/22
Significant Family History: Father has history of Diabetes which is well controlled with insulin and Mother had hypertension before her death at the age of 60 years in 2021 due to complication of coronavirus.
Review of Systems:
General: Ms Caroline is in a stable condition, no obvious distress noted. She just doesn’t feel good about the recent skin changes since she got pregnancy as that is her first pregnancy.
HEENT: Ms. Caroline denies having any problems with hearing, vision, nasal congestions, nil swelling and no remarkable change on the throat.
Respiratory: Ms Caroline denies any breathing problems
Cardiovascular/Peripheral Vascular: Ms Caroline denies any episodes of irregular heartbeats, denies any heart murmur and not chest pain.
Gastrointestinal: Patient denies any problems with appetite. Confirmed she has regular bowel movements. Patient is positive for constipation occasionally.
Genitourinary: Patient denies any history of urinary tract infection.
Musculoskeletal: Patient is positive mild back pain which she takes regular Tylenol 375mg orally every 8 hrs. when needed.
Neurological: Patient is alert and oriented, no neurological deficit noted. Denies any history of epilepsy or seizures.
Psychiatric: Patient denies any history of mental health illness.
Skin/hair/nails: Ms Caroline is very much concerned about the new stretch
marks that runs through her abdominal wall. Patient does not have any other skin alteration. Patient complained of hair dandruff.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Patients blood pressure measured on the right arm was 144/81, Temperature is 97.7 degree Fahrenheit, Pulse is 72bpm, Respiration is 17c/m, Weight is 179 pounds, height is 5 feet 6 inches and a calculated BMI of 28.9.
General: Ms. Caroline came in alert and oriented to time and place. The vital signs showed that the patient is overweight with a BMI of 28.9 and blood pressure is elevated.
HEENT: On examination of the hair, there were presence of dandruff on the scalp.No inflammation noted on the tonsil and no tenderness noted at the temporomandibular joint. The pupils were equal, round, reactive to light. No discharges noted from ears.
Neck: There was normal range of motion, and no distended juggler vein noted.
Chest/Lungs: The trunk was clear. The intercostal movements were nornmal.no abnormal breath sounds like wheezes. Respiration rate of 18 b/min.
Heart/Peripheral Vascular: On auscultation, the S1 and S2 heart sounds were present and heart rate was within normal limits of 72bpm.
Abdomen: There was positive fetal heart rate of about 128b/m and thee were marked indented streaks on the abdominal wall.
Genital/Rectal: The vagina was free from any signs of infection, nil swelling, discharge or inflammation noted during assessment of the genitalia.
Musculoskeletal: There are no muscle or joint pains noted and there is full range of motion with no limitation.
Neurological: Mrs Caroline is oriented to time, place and person. Patient scored high on assessment of mental status. The mental assessment shows patient has memory intact both recent and past events.
Skin: Patients skin is warm to touch with a temperature of 97.8, nil discoloration noted except the indented stretch marks on the abdominal wall
Diagnostic results:
- There was Lab draw for White blood count which was unremarkable for infection
- On observation of the skin, the streaks and discoloration of the skin were present
- A culture of the skin is important to rule other causes of skin infections.
- Scraping of the nail and skin is key to rule out infections of the skin (Colyar,2015).
ASSESSMENT:
Differential diagnoses
- Linea nigra
- Linear focal elastosis
- Striae from topical steroid abuse, such as in the treatment of psoriasis.
- Cushing’s syndrome.
Primary diagnosis:
After a thorough consideration of other possible causes of this condition, I was able to narrow down the diagnosis based on my assessments and patients present condition to be Striae gravid arum.
Pregnancy as we all know comes with different skin changes as the body adjust to the new normal of accommodating the baby such as the changes that occur within the connective tissues as the skin continues to stretch as the uterus enlarges leads to the stretch marks (Ball, J et.all 2019). This evidence of stretch march shows poor skin elasticity which further puts the patient at risk perineal or vaginal tears due to poor elasticity. When stretch marks becomes evident, it’s as a result of damage to the dermal collagen and further dilation of blood vessels (Dains, Baumann & Scheibel, 2019).
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
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.
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.
Sample Answer 3 for Assignment NURS 6512 Differential Diagnosis for Skin Conditions
SUBJECTIVE DATA:
Chief Complaint (CC): “I have some stretch marks and a line on my abdomen’
History of Present Illness (HPI): A.T. is a 28-year-old female client that came to the clinic with complaints of abnormal stretch marks and a line on her abdomen. The client is pregnant. The gestation of her pregnancy is 28 weeks. She has never started her antenatal clinic visits. The patient reports that the problem started four weeks ago and she was hopeful that it would diminish over time. She denied any associated symptoms such as pain or itchiness. However, she was worried that she may be having a skin condition that would require immediate intervention. She has not used any skin medications for the problem.
Medications: The patient denied any current use of medications. She reported occasional use of Tylenol 1 gram for headaches.
Allergies: The patient reported allergic reaction to Penicillin and pollen. She denied food allergies.
Past Medical History (PMH): The patient reported a history of hospitalization when she was 18 years old because of pneumonia. She denied any history of chronic conditions such as diabetes and depression. She also denied any history of blood transfusion.
Past Surgical History (PSH): The patient denied any history of surgeries
Sexual/Reproductive History: The patient is sexually active. Her last menstrual period was 21/10/2022. She denied any history of sexually transmitted infections. She also denied any history of increased urgency, frequency, and dysuria. She does not have any history of pregnancy loss or use of contraceptives. She is heterosexual.
Personal/Social History: The patient is married. She is the first born in a family of three. Her parents are both alive. This is her first pregnancy. She works as an accountant in a local firm. She does not use alcohol or smokes. She engages in moderate physical activities twice weekly. She is a Christian. She considers her family her source of social support. She denies stress.
Health Maintenance: The patient engages in moderate exercises twice weekly. She does not take alcohol or smokes. She reports that she takes healthy diet. Her immunization record is up-to-date. She has not started her antenatal clinic despite her pregnancy being 28 weeks. She denies caffeine use. She has not undergone cervical cancer screening. She performs monthly self-breast examination. Her last dental and eye examinations were two years ago and were unremarkable.
Immunization History: Her immunization record is up-to-date.
Significant Family History: The client reports that her parents are both hypertensive. Her mother is diabetic. Her paternal grandmother and grandfather died of coronary artery disease. Her maternal grandmother died of cervical cancer. Her sister is obese. Her brother was recently diagnosed with substance use disorder.
General: The patient is well dressed for the occasion. She denied fatigue, fever, chills or night sweats. Reports weight gain of 10 pounds since she became pregnant.
HEENT: She denies changes in vision or hearing; she does wear glasses. She has no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She has had no recent ear infections, tinnitus, or discharge from the ears. She denied changes in sense of smell. She does not have a history of nasal polyps or recent sinus infection. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.
Neck: She denies pain, injury, or history of disc disease or compression..
Breasts: She denies history of lesions, masses or rashes.
Respiratory: She denies cough, hemoptysis, difficulty breathing or chest pain. She a history of community acquired pneumonia when she was 18 years.
CV: She denies chest discomfort, palpitations, history of murmur. She has no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication.
GI: She denies nausea or vomiting, abdominal pain. She also denies changes in bowel/bladder pattern.
GU: She denies change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She denies history of STD’s or HPV. She is sexually active.
MS: She denies arthralgia/myalgia, arthritis, gout or limitation in her range of motion.
Psych: She denies history of anxiety or depression. She also denies sleep disturbance, delusions or mental health history.
Neuro: She denies syncope episodes or dizziness, paresthesia, change in memory or thinking patterns. She also denies twitches or abnormal movements, gait disturbance, falls or seizure history.
Integument/Heme/Lymph: She reports stretch marks and a line in the middle of her abdomen. She denies rashes, itching, or bruising.
Endocrine: She denies polyuria/polyphagia/polydipsia. She also denies fatigue, heat or cold intolerances, or shedding of hair
Allergic/Immunologic: She is allergic to Penicillin and pollen. She has no food allergies.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 124/78, left arm, sitting, regular cuff; P 82 and regular; T 99.9 Orally; RR 20; non-labored; Wt: 168 lbs; Ht: 6’5
General: A&O x3, NAD
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jugular venous distention or thyromegally
Chest/Lungs: Lungs clear of wheezing or rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: presence of bilateral strae gravidarum and central linea nigra. Normal bowel sounds with no organomegaly and suprapubic
Genital/Rectal: Non-contributory
Musculoskeletal: symmetric muscle development. Muscle strengths 5/5 all groups.
Neuro: Normal cranial nerve assessment with no gait imbalance or coordination problems. There is no loss of sensitivity to touch.
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Diagnostic results: Obstetrics ultrasound performed one day ago: Intrauterine live pregnancy at 28/40 weeks in breech presentation. FHR-132 bpm, BPP 8/8, cervix closed
ASSESSMENT:
Differential Diagnosis
- Linea nigra: Linea nigra is a hyperpigmentation characterized by a vertical line running down the middle of the abdomen. It is an indicator of pregnancy.
- Strae gravidarum: Strae gravidarum refers to atropic linear scars that pregnant mothers develop. The form as stretch marks on the abdomen and diminish over time.
- Post-inflammatory hyperpigmentation: Post-inflammatory hyperpigmentation is a disorder that develops after skin injury or inflammation. It is severe in dark-skinned individuals. It improves spontaneously but can also require treatment for immediate changes (Lawrence & Al Aboud, 2023). It is the least likely condition since the patient in the case study is pregnant.
- Melanocytic naevi: Melanocytic nevi are benign hematomas or neoplasms that cause skin hyperpigmentation. It mainly affects the central nervous system and the skin. Melanocytic nevi are the least likely cause of the client’s problem since they do not occur in features such as midline vertical line that is seen in pregnancy (Yeh, 2023)
Primary diagnosis
- Normal pregnancy with features that include linea nigra and strae gravidarum: The client’s primary diagnosis is normal pregnancy with features that include linea nigra and strae gravidarum. Linea nigra is a normal occurrence in pregnant women. It refers to a form of hyperpigmentation that is witnessed in pregnancy. It is a dark vertical line running down the middle of the abdomen. It is an indicator of pregnancy. Linea nigra is associated with nipple, genital areas, and areola hyperpigmentation (Cappanera, 2022; Ferrando et al., 2019; Sharma et al., 2019). Strae gravidarum refers to atrophic linear scars that develop on the abdomen during pregnancy. They appear as stretch marks that may be of considerable concern to pregnant women (Dai et al., 2021). Strae gravidarum is non-pathological. The stretch marks fade over time and become hypopigmented (Karhade et al., 2021). The patient in the case study has these features, hence, a diagnosis of linea nigra and strae gravidarum. The patient is also pregnant, hence, the primary diagnosis with these conditions.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
References
Cappanera, F. F., Gisella Sorrentino, Elena. (2022). Linea Nigra: Post/Human M/Others. In Engaging Donna Haraway. Routledge.
Dai, H., Liu, Y., Zhu, Y., Yu, Y., & Meng, L. (2021). Study on the methodology of striae gravidarum severity evaluation. BioMedical Engineering OnLine, 20(1), 109. https://doi.org/10.1186/s12938-021-00945-w
Ferrando, B. F., Sorrentino, G., & Cappanera, E. (2019). Linea Nigra: Post|Human M|Others. A/b: Auto/Biography Studies, 34(3), 501–505. https://doi.org/10.1080/08989575.2019.1664152
Karhade, K., Lawlor, M., Chubb, H., Johnson, T. R. B., Voorhees, J. J., & Wang, F. (2021). Negative perceptions and emotional impact of striae gravidarum among pregnant women. International Journal of Women’s Dermatology, 7(5, Part B), 685–691. https://doi.org/10.1016/j.ijwd.2021.10.015
Lawrence, E., & Al Aboud, K. M. (2023). Postinflammatory Hyperpigmentation. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559150/
Sharma, A., Jharaik, H., Sharma, R., Chauhan, S., & Wadhwa, D. (2019). Clinical study of pregnancy associated cutaneous changes. International Journal of Clinical Obstetrics and Gynaecology, 3(4), 71–75. https://doi.org/10.33545/gynae.2019.v3.i4b.292
Yeh, I. (2023). Melanocytic naevi, melanocytomas and emerging concepts. Pathology, 55(2), 178–186. https://doi.org/10.1016/j.pathol.2022.12.341
Sample Answer 5 for Assignment NURS 6512 Differential Diagnosis for Skin Conditions
SUBJECTIVE DATA:
Chief Complaint (CC): Painful rash and joint pain
History of Present Illness (HPI): During the day, AB a 23-year-old lady was presented to the clinic with an onset of painful plague like rashes and pain her joints that started two weeks ago. She added that the rashes started on her knees and later to her elbows and scalps. She further reported the rashes are itchy and sore and complained her joints have painful for the past three weeks. The condition makes her annoyed and worsens as the days go by. More importantly, she added she takes painkillers (Ibuprofen 400mg three times a day) to relieve the pain as well change her laundry detergent with no improvement on her condition.
Onset – Rashes three days
Location – Knee
Duration – Three weeks ago
Character- gradual
Associated symptoms – none
Relieving factors – Painkillers
Treatment – None
Severity – 6/10
Medications:
Takes Ibuprofen 400mg three times a day as prescribed in her local pharmacy.
Multivitamin for women I tablet daily
Allergies: Denies drug or food allergies.
Past Medical History (PMH):
Frequent Tonsillitis
Past Surgical History (PSH):
Tonsillectomy 2006
Caesarian section 2014
Sexual/Reproductive History:
In a monogamous relationship
Menarche 9 years and 8 months
Gravida 1, Parity 0
She experiences regular menstruation
Denies any history of sexually transmitted diseases
She is on Nexplanon contraception for 3 years now
She has her last pap smear in 2018 and results were normal
Social History:
Denies smoking and ETOH intake or substance abuse. She maintains a balanced diet and exercises when she can.
Immunization History:
AB is immunization is up to date according to the World Health Organization. She had a flu vaccine towards the end of last year and her Tdap in 2017 does not fulfill the standards for pneumonia immunization.
Lifestyle:
AB has been working as a receptionist in a local insurance company for the last three months now. AB lives with her elder sister after she had broken up with her boyfriend two years ago. However, she is looking for her own apartment since they have had some differences with her sister. Her sister’s apartment is quite confined after she delivered a baby some months ago as she uses AB’s room as her child’s newborn nursery. As such, she is forced to sleep on the couch with her child. In addition, she helps in nursing her sister and stays late in the night helping with the baby. Luckily, AB has her own health insurance policy and she usually has regular health examination, takes a balanced diet and goes to the gym thrice in a week. More importantly, she agrees the family support is tense due to the newborn and barely have friends to visit her.
Family History
According to AB reports, her father is 47 years of age, and her 43 years old. She is a second born in a family of 4. Both her maternal grandmother mother and paternal grandfather aged 65 and 68 years old respectively have a history of psoriasis and eczema as well as psoriasis arthritis and psoriasis respectively. His father although separated with her mum now, he has a history of multiple allergies and psoriasis. In addition, her mother was diagnosed with breast cancer in 2013 and she is currently in remission. Her two younger brothers were recently diagnosed with an unknown fungal infection.
Review of Systems:
General: Denies having fever, chills, fatigue, night sweats, or significant weight changes
HEENT:
Head/face: No hair loss or head injury, denies headache,
Eyes: Round pupils and reactive to light, Moist mucus Membranes
Ears: Denies having any hearing problems. No tinnitus, no drainage
Nose: No epistasis, nasal congestion, denies having allergies and nasal drainage.
Mouth/Throat/ Neck: Denies sore throat, supple neck, no stiffness, no thyromegaly, no
Lymphadenopathy, no toothache. She had the last dental exam on 20th August 2018.
Musculoskeletal: Positive for diffuse joint pain. No cyanosis, no edema or clubbing. No tenderness on her scapular. Positive dorsalis and radial pulses (2+). Denies any history for gout, arthritis fractures or trauma.
Psychiatric: AB is experiencing social problems, increased stress and sleep problems. However, denies having anxiety depression or suicidal thoughts in the past.
Skin: Polycyclic and pinkish orange-colored plaques approximately 1 cm in size present on her knees, elbows, and scalp, sore and pruritic. No pigment change noticed.
Allergic/Immunologic: Denies any history of drug or food allergies. No known seasonal allergies or immunological condition.
OBJECTIVE DATA:
Physical Exam:
Vital signs: SpO2: 98% tympanic; Ht: 5’7”, Wt: 131lbs, BMI: 23.8, BP 112/68 right arm, sitting, regular adult cuff; Pain severity 6/10; Respiratory Rate- 17, non-labored.
General: AAOx4. Appears neat with a well-kempt hair. Maintains eye contact, fluent in speech and
cooperative.
HEENT: PERRLA, EOMI, normal head traumatic and cephalic, dry oral mucosa, pure oropharynx. Identical pupils, no nasal deviation.
Musculoskeletal: Positive mild swelling on the wrist, knee, and ankle joints bilaterally with pain present. Symmetric muscle development
Skin: Pinkish orange-colored, hoary, polycyclic plaques approximately 1cm in size with discrete borders present on the scalp, elbows, and knees. Sore and a bit painful to palpation. Thick acrylic nails present, limiting nail assessment
Lab Tests and Results:
A complete blood count (CBC) – white blood cells counts (WBC) – 8,500 cells/mcL
Diagnostics:
- Skin biopsy
- Positive for psoriasis.
- Negative for fungal infection
ASSESSMENT:
Primary Diagnosis: Psoriasis
Differential Diagnoses:
- Nummular eczema
- Lichen Planus
- Mycosis Fungoides
- Allergic contact dermatitis
- Duhring’s disease
Based on the clinical manifestation presented characterized by rashes and joints paints, it is evident the patient is suffering from psoriasis. Psoriasis is a common condition characterized by dry, raised and red skin lesions covered with silvery scales anywhere in the body such as genitals and on soft tissue. Moreover, plaques or lesions might be itchy and painful (Langley et.al., 2014). Anyone can develop psoriasis. However, family history is one of the most significant risk factors. AB’s family has a history of Psoriasis condition. According to the client, both her maternal grandmother and paternal grandfather suffered from psoriasis and eczema as well as psoriasis arthritis and psoriasis respectively putting her at higher risk of developing the condition. In addition, life stressors can impact significantly on the immune system. As such, high-stress levels increase the risk of psoriasis (Di Meglio & Nestle, 2017). The descriptions of the rashes and their location point out towards the diagnosis of psoriasis. Upon diagnosis of psoriasis, the patient complains of joint pains suggesting she might be suffering from psoriasis arthritis (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
However, despite the lesions/plagues being pinkish orange, all the other differential diagnosis was ruled through skin biopsies. More importantly, Mycosis Fungoides and Lichen Planus are caused by fungi and the skin biopsy results were negative for fungal infection and lichen planus plaques are white (Napolitano et.al.,2016). In addition, the patient does not have any allergies to foods and drugs or immunization disorder hence she could not be diagnosed with allergic contact dermatitis. Furthermore, the patient could not be diagnosed with nummular eczema are allergic related, but the patient does not have any allergic or immunization disorder and the plaques are associated with extensive scratching
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Napolitano, M., Caso, F., Scarpa, R., Megna, M., Patrì, A., Balato, N., & Costa, L. (2016). Psoriatic arthritis and psoriasis: differential diagnosis. Clinical rheumatology, 35(8), 1893-1901.
Di Meglio, P., & Nestle, F. O. (2017). Immunopathogenesis of Psoriasis. In Clinical and Basic Immunodermatology (pp. 373-395). Springer, Cham.
Langley, R. G., Elewski, B. E., Lebwohl, M., Reich, K., Griffiths, C. E., Papp, K., … & Rivas, E. (2014). Secukinumab in plaque psoriasis—results of two phases 3 trials. New England Journal of Medicine, 371(4), 326-338.