Assignment 1 Lab Assignment 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.

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 (identified 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.

Differential Diagnosis for Skin Conditions Sample Paper

Skin Condition Picture # 5

Patient Initials: ___AB_____   Age: _____23__   Gender: ___M____

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 in 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 been 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 400 mg three times a day) to relieve the pain as well as changing 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
  • Cesarean 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 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 examinations, 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 has 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 from her mum now, 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 conditions.

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 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 1 cm 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

Ø  Positive for psoriasis.

Ø  Negative for fungal infection

ASSESSMENT:

Primary Diagnosis: Psoriasis

Differential Diagnoses:

1    Nummular eczema

2    Lichen Planus

3    Mycosis Fungoides

4    Allergic contact dermatitis

5    Duhring’s disease

Based on the clinical manifestation presented characterized by rashes and joint 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 conditions. 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 that 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.