Differential Diagnosis:

Atopic dermatitis: Atopic dermatitis is the most likely diagnosis in this case. Atopic dermatitis is a chronic inflammatory skin condition which typically presents as a pruritic rash. Atopic dermatitis is most commonly seen in children which fits this patients demographics and the pruritus is a common feature of this condition. This patient has a family history that is significant for asthma, allergic rhinitis, and food allergies which is commonly seen in patients with atopic dermatitis and is the strongest risk factor for development of this condition which makes me highly suspicious that this rash is consistent with atopic dermatitis. This patient first developed these symptoms at the age of 4 which is consistent with a typical age of onset of atopic dermatitis at age 5 (Howe,2023).  Excessively hot or cold environments can trigger an exacerbation of atopic dermatitis so the fact that this patient often has flare ups in the winter and also had exacerbation after returning from a vacation in a tropical climate further supports the diagnosis of atopic dermatitis (Dunphy et al.,2019). The diagnosis is further supported by the affected body parts of the popliteal and antecubital fossae which is the most common presentation of atopic dermatitis in children (Dunphy et al.,2019). The presence of Dennie-morgan lines also supports the diagnosis of atopic dermatitis and is often seen in this condition (Garzon et al.,2020). Atopic dermatitis is typically diagnosed based upon clinical presentation and history alone and ruling out other skin conditions (Dunphy et al.,2019)

Impetigo: In this patient he may have two skin conditions present as separate issues. On exam he does have Impetigo “crust-like” lesions with serum oozing found on the left elbow (Dunphy et al.,2019). Impetigo is the most common bacterial skin condition that occurs in the pediatric population and presents as a superficial vesiculopustular infection that is highly contagious (Dunphy et al.,2019). This diagnosis would need to be included on the differential due to the description of the area and how common it is in the pediatric population and even more common in atopic dermatitis due to breaks in the skin from scratching. Impetigo typically presents with pruritus and is often found on the extremities which fits with this clinical picture (Dunphy et al.,2019). Often impetigo is diagnosed based on clinical presentation and history however, it can be confirmed by culture (Dunphy et al.,2019). Due to the highly contagious nature of impetigo the diagnosis would further be supported if someone else exposed to the patient had the same presentation, this is not present in the case but doesn’t rule out the condition (Dunphy et al.,2019).

Psoriasis: Another condition to consider as part of the differential diagnosis in this patient would be psoriasis. Psoriasis is a skin condition that will also present with erythematous, scaly plaques commonly on the extensor elbows and knees (Dunphy et al.,2019). The diagnosis of psoriasis should also be considered in this case because like atopic dermatitis it is also triggered by either an excessively cold environment or triggered by prolonged exposure to sunlight which is consistent with this case (Dunphy et al.,2019). This diagnosis is less likely in this patient because he fits less with the clinical picture of psoriasis which typically has an age of onset either in the late teens to early 20s or late 50s to early 60s (Dunphy et al.,2019). This patient was asked about joint pain because patients with psoriasis may also experience psoriatic arthritis where joints are affected and painful (Dunphy et al.,2019). In this case the patient has no joint pain. Often a diagnosis of psoriasis can be made based on clinical presentation and history alone. In this case the presentation, history, and demographic features of the patient are more consistent with atopic dermatitis (Dunphy et al.,2019)

Contact dermatitis:  This is a common skin condition that is either caused by an allergic immune mediated response or caused by irritation after repeated insults to contact with a caustic substance (Dunphy et al.,2019). This condition should be considered because of its prevalence and its typical presentation of a pruritic, erythematous rash. Four to seven percent of all dermatologic consultation are made due to contact dermatitis (Dunphy et al.,2019). This diagnosis is less likely in this case because the patient does not fit with the typical clinical picture for contact dermatitis which is more common in adult women (Dunphy et al.,2019). The diagnosis is also less likely as the patient’s parent denies any exposures to any new soaps, lotions or detergents and reports being very careful about what the patient is exposed to. The diagnosis of contact dermatitis is based on the clinical presentation and history which in this case is more consistent with atopic dermatitis (Dunphy et al.,2019)

Plan:

Primary Differential Diagnosis: Atopic dermatitis and case of impetigo on elbow

Pharmacology

The mainstay of treatment for atopic dermatitis in children is the lowest potency steroid possible for the shortest amount of time possible. Hydrocortisone 2% topically has already been tried which is a lower potency topical steroid. I would recommend applying a small amount of a higher potency topical steroid of triamcinolone 0.1% ointment twice a day for no more than two weeks. Will re-evaluate in the office in two weeks (Garzon et al.,2020).

Benadryl can help with pruritus and also help with sleeping at night due to its sedative properties. However, I would recommend discontinuing the Benadryl because sedating antihistamines are not generally recommended for children because they can cause daytime drowsiness which can negatively impact school performance and they can also have a paradoxical effect of causing hyperactivity in some children (Dunphy et al.,2019)

Would prescribe mupirocin 2% ointment topically twice a day for 5 days for the area of impetigo on the elbow ( Garzon et al.,2020).

Would recommend decreasing the Zyrtec to 5 mg daily which is the pediatric dosage.

Non-Pharmacology

A mild emollient such as Cetaphil should be used as substitute for soap.

Soak baths should be used instead of showering followed by liberal application of moisturizers after the skin is partially patted dry.

Any products containing strong scents, coloring agents, or perfumes should be avoided

(Dunphy et al.,2019)

Diagnostics: Would order an allergy panel ; would culture the oozing lesions for bacterial sensitivities.

Consults/Referrals: Referral to dermatology

Referral to allergist

(Dunphy et al.,2019)

Patient education:

1.      The impetigo is contagious until 24 hours of antibacterial treatment has been completed so need to avoid exposure to others (Garzon et al.,2020).

2.      Thorough cleansing of any skin breaks will help prevent impetigo (Garzon et al.,2020).  

3.      Need to avoid any contact with persons with active herpetic lesions to prevent development of eczema herpeticum (Dunphy et al.,2019)

4.      Discuss how to monitor for secondary signs of bacterial infections that require evaluation (Dunphy et al.,2019)

5.      Discuss need to avoid triggers such as dust mites, pollen, and animal dander (Dunphy et al.,2019)

6.      Discuss ways to reduce sweating such as light bedclothes at night and avoiding occlusive garments (Dunphy et al.,2019)

7.      Fingernails need to be kept short and clean to avoid colonization with S. aureus to open skin areas from scratching (Dunphy et al.,2019).

8.      Need to upgrade moisturizers during the fall to petroleum jelly (Dunphy et al.,2019)

9.      I would discuss the use of bleach baths once or twice a week (Dunphy et al.,2019)

10.  I would discuss that the triamcinolone cream needs to be used for the shortest amount of time possible in order to reduce the risk of potential side effects such as thinning of the skin (Dunphy et al.,2019).

11.  I would discuss that triamcinolone cream should not be used on the face (Dunphy et al.,2019)

12.  Would discuss that topical steroids need to be used for shortest period of time possible because systemic absorption can lead to growth impairment, and cataract formation (Dunphy et al.,2019)

Follow up: I would recommend two week follow up appointment for evaluation if treatment has been effective.

Health Maintenance: An important item for health maintenance related to dermatology would be discussing sun protection including the use of sunscreen and protective clothing including wide brimmed hats when outside to protect the skin. This will help prevent flares of atopic dermatitis due to the fact that excessive sun exposure can cause flare ups (Dunphy et al.,2019).

Social Determinants of Health: Severe eczema is associated with denial of eczema prescriptions by insurance carriers or a lack of health insurance (Buckstein et al.,2022). The health care provider needs to think of the cost of medications and what insurance will cover when making treatment decisions. If an effective medication is prescribed but insurance will not cover or it is expensive then the patient is less likely to comply with treatment as they may not be able to afford to pick up the prescription. In this case, triamcinolone topical cream was prescribed because this is a medication that will likely be covered by insurance. There is a newer medication crisaborole that has been approved for the treatment of moderate atopic dermatitis that is effective in reducing itching that I would consider if the current treatment regimen is ineffective (Howe, 2023). However, due to the fact that the patient’s financial resources need to be taken into account this would not be in the primary treatment plan

References

Bukstein, D. A., Friedman, A., Gonzalez Reyes, E., Hart, M., Jones, B. L., & Winders, T. (2022).

Impact of social determinants on the burden of asthma and eczema: Results from a US patient survey. Advances in therapy, 39(3), 1341–1358. https://doi.org/10.1007/s12325-021-02021-0

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th

            ed.). F. A. Davis Company.

Garzon, M. D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K. (2020). Burns’ Pediatric Primary Care (7th ed.). Elsevier.

Howe, W. (2023) Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and

diagnosis . Uptodate.Retrieved March 18, 2023 from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/atopic-dermatitis-eczema-pathogenesis-clinical-manifestations-and-diagnosis

Value: 100 points

Due: Create your initial post on Day 3, Initial Response post by Day 5, and Reflective Response by Day 7.

Gradebook Category: Simulated OV Discussions

Introduction

Prior to completing this first discussion forum, please watch the Discussion Board Directions video for more information on how to complete the forums.

Discussion Board Instructions (2:53 Minutes)

Discussion Board Instructions Video Transcript

Initial Post

Imagine that you are a primary care provider in the middle of your busy Thursday and your 4:15 pm appointment is as follows:

HPI: A 9-year-old boy, Taumi, with a history of recurrent skin infections presents with extensive redness and pruritus of the popliteal and antecubital fossae, arms, and abdomen. He’s scratched the lesions, especially at night, with the result that his sleep was disturbed. Despite the use of chronic moisturizing therapy and topical corticosteroids, he is having a seasonal flare of his condition. When he was 6 years old, he also experienced bronchial asthma with a persistent cough. This is not the first time he’s experienced this type of rash and has had issues since he was 4 years old. His mothers, Patricia and Fran, are bringing him into the clinic today for another exacerbation. They have tried the following: diphenhydramine 25mg q8h prn, hydrocortisone 2% QID, Zyrtec 10mg QD, and Aquaphor QID. The medications help some, but he’s still uncomfortable.

Family history: His father has asthma, and his younger sister has allergic rhinitis and cow’s milk allergy.Physical Exam:

• Vitals: BP 102/60, HR 68, RR 18, Wt 88 lbs (22 kg), Ht 4’11”
• HEENT: Injected conjunctivae and presence of Dennie-Morgan lines. There was a ‘cobblestone’ appearance of his posterior pharynx.
• Respiratory: Lungs were clear bilaterally with good aeration.
• Cardiac and abdominal examinations were unremarkable.
• Integumentary: Skin examination demonstrated scattered scaly eczematous patches along with the flexural areas of his upper and lower extremities. Impetigo “crust-like” lesions with serum oozing were found on the left elbow.

Complete the following:

Initial Post by Wednesday (Day 3) at 11:59 p.m.

• List 10–20 questions of subjective information that your patient will need to provide to help you formulate your differential diagnoses and plan. Include two scholarly references for the questions that you ask of your patient. See the Grading Rubric for more detail.

Initial Response Post by Friday (Day 5) 11:59 p.m. Choose a classmate’s questions to answer:

• Every peer post should only have one response post. Please do not reply to a peer if a response is already posted.
• You are answering as the patient. Make it case appropriate but imaginative. Be creative and answer thoroughly. No references are needed.

Reply Posts

Reflective Response Post by Sunday (Day 7). Please respond with the following:

• Four appropriate differential diagnoses and rationales with references. For each differential diagnosis, explain why this is an appropriate differential and how it was/would be ruled in or out. Support your answers with references.
• Pick one differential and create a plan of care for that patient.
  • Plans must include Pharmacology, Non-Pharmacology, Labs/Diagnostics, Referrals/Interprofessional Communications, Patient Education (10–15 individual items minimum) and follow up.
  • Make sure to pick one health maintenance item for this patient (primary or secondary) and explain to the patient why this is important.
  • Address one social determinant of the health this patient may face during your visit. How will you help the patient overcome this obstacle to health care?

Please refer to the Grading Rubric for details on how this activity will be graded.

Posting to the Discussion Forum

1. Select the appropriate Thread.
2. Select Reply.
3. Create your post.
4. Select Post to Forum.

This is a question and answer forum. In order to see other responses to these questions, you must first post your answer

Simulated Office Visit Assignment Rubric

Note: Scholarly resources are defined as evidence–based practice, peer–reviewed journals; textbook (do not rely solely on your textbook as a reference); and National Standard Guidelines. Review assignment instructions, as this will provide any additional requirements that are not specifically listed on the rubric.

Criteria	Exemplary Exceeds Expectations	Advanced Meets Expectations	Intermediate Needs Improvement	Novice Inadequate	Total Points
Initial Post	Post includes 10–20 questions of subjective information that are appropriate for the patient vignette. Questions are targeted toward the content of the vignette. Questions are supported by appropriate references. Initial Post by Wednesday (Day 3) at 11:59 p.m. 30 points	Post includes questions of subjective information that are appropriate for the patient vignette. Questions are general and NOT targeted toward the content of the vignette. Questions are supported by appropriate references. Initial Post by Wednesday (Day 3) at 11:59 p.m. 26 points	Post includes less than 10–20 questions of subjective information and/or are not appropriate for the patient vignette. Questions are vague. Questions are supported by appropriate references. Initial Post is late. 23 points	Post includes less than 10–20 questions of subjective information and/or are not appropriate for the patient vignette. Questions are vague or not appropriate for patients. Questions are NOT supported by appropriate references. Initial Post is late. 20 points	30
Initial Response Post	Student answers ALL peer’s questions appropriately, as the patient. Answers drive discussion and analysis forward. Initial Response Post by Friday (Day 5) 11:59 p.m. 30 points	Student answers ALL peer’s questions appropriately, as the patient. Answers struggle to drive discussion and analysis forward. Initial Response Post by Friday (Day 5) 11:59 p.m. 26 points	Student does not answer ALL questions appropriately or from patient perspective. Initial Response Post by Friday (Day 5) 11:59 p.m. 23 points	Student does not answer ALL questions appropriately or from patient perspective. Questions are irrelevant or do not makes sense. Initial Response Post is late. 20 points	30
Reflective Response Post	Student replies to additional post with 4 appropriate differentials and rationale that are well supported by evidence. Appropriate and evidence–based plan of care is developed for one differential; supported by references. Reflective Response Post due by Sunday (Day 7) 11:59 p.m. 30 points	1–2 minor omissions from differentials or plan of care. These do not constitute missing must not miss differentials or safety issues. Reflective Response Post due by Sunday (Day 7) 11:59 p.m. 26 points	3+ minor omissions from differentials or plan of care. These do not constitute missing must not miss differentials or safety issues. Reflective Response Post due by Sunday (Day 7) 11:59 p.m. 23 points	1–2 major omissions from differentials or plan of care. These constitute missing must not miss differentials or safety issues. Reflective Response Post due by Sunday (Day 7) 11:59 p.m. Responses after Day 7 will not receive any credit. 20 points	30
Organization	Well–organized content with a clear and complex purpose statement and content argument. Writing is concise with a logical flow of ideas. 5 points	Organized content with minimal issues in content flow. 4 points	Poor organization, and flow of ideas distract from content. Narrative is difficult to follow and frequently causes reader to reread work. 3 points	Illogical flow of ideas. Missing significant content. Prose rambles. Purpose statement is unclear or missing. Demonstrates incomplete understanding of content and/or inadequate preparation. 2 points	5
APA, Grammar, and Spelling	Correct APA formatting with no errors. There are no spelling, punctuation, or word–usage errors 5 points	Correct and consistent APA formatting of references and cites all references used. No more than two unique APA errors. The writer demonstrates correct usage of formal English language in sentence construction. Variation in sentence structure and word usage promotes readability. There are minimal to no grammar, punctuation, or word–usage errors. 4 points	Three to four unique APA formatting errors. The writer occasionally uses awkward sentence construction or overuses/inappropriately uses complex sentence structure. Problems with word usage (evidence of incorrect use of thesaurus) and punctuation persist, often causing some difficulties with grammar. Some words, transitional phrases, and conjunctions are overused. Multiple grammar, punctuation, or word usage errors. 3 points	Five or more unique formatting errors or no attempt to format in APA. The writer demonstrates limited understanding of formal written language use; writing is colloquial (conforms to spoken language). The writer struggles with limited vocabulary and has difficulty conveying meaning such that only the broadest, most general messages are presented. Grammar and punctuation are consistently incorrect. Spelling errors are numerous. 2 points	5
Total Points					100