NURA 6512 Lab Assignment Differential Diagnosis for Skin Conditions

Assessment

Tinea Barbae

Tinea barbae is an infection of the superficial dermatophyte that occurs on the bearded areas of the face and neck. It occurs almost solely in older adolescents and adult males (Kuruvella & Pandey, 2021). It most often affects farmers due to contact with an infected animal since a zoophilic organism causes it. Tinea barbae presents with a characteristic lesion, an inflammatory red nodule with pustules, and draining sinuses on the surface (Kuruvella & Pandey, 2021). The beard hairs are usually loose or broken, and removing the hair is easy and painless. The pus-filled white masses affect the hair root and follicle (Singh et al., 2017). Tinea barbae is a priority differential diagnosis based on the patient’s findings of inflamed and red lumpy areas on the lower beards and red pustules with crusting around the beard hairs. Besides, the patient’s beard hairs are broken and easily plucked. The patient could have contracted the infection from an infected animal at the ranch. A direct microscopy culture will help in confirming the diagnosis.

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Bacterial Folliculitis

Bacterial folliculitis is an inflammation of the hair follicle caused by infection, physical injury, or chemical irritation. It is primarily caused by Staphylococcus aureus (Jappa & Sameer, 2018). Bacterial folliculitis mostly occurs in skin areas exposed to occlusion, rubbing, and sweating, including the face, neck, axillae, and buttocks (Lin et al., 2018). Persons with superficial folliculitis usually have an acute onset that occurs with pruritus or mild discomfort. Deep folliculitis typically has longer-standing lesions, and patients frequently report pain and, at times, suppurative drainage. Recurrent lesions can cause scarring and permanent hair loss. Superficial folliculitis presents with many small papules and pustules on an erythematous base pierced by a central hair, although the hair is not always visualized (Jappa & Sameer, 2018). Folliculitis is a differential diagnosis based on patient symptoms of pruritus and mild pain on the beard and pustules and crusting on an erythematous base.

Pseudofolliculitis Barbae:

Pseudofolliculitis barbae is a form of folliculitis involving the beard area. It is caused by infection with Staphylococcus aureus. It is a chronic inflammatory condition of follicular and perifollicular skin (Ogunbiyi, 2019). I presents with pustules, papules, and post-inflammatory hyperpigmentation. It occurs mostly in males of African and Asian descent. Patients report experiencing a painful eruption of acne after shaving (Ogunbiyi, 2019). It presents with an erythematous papule having a hair shaft in its center. The patient’s symptoms consistent with pseudofolliculitis barbae include pustules and erythematous at the beard area.

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Reflection

The clinical experience has enlightened me on dermatological conditions affecting the beard area. I have learned that various bacteria or fungal infections can cause the conditions. Besides, I learned that the clinician should be keen during the examination to differentiate if a patient has papules (pimples with no visible pus) or pustules (pus-filled pimples), which helps differentiate the dermatological condition. If I were to repeat the assessment, I would perform a culture to identify the specific causative microbe.

References

Jappa, L. S., & Sameer, R. K. (2018). A clinical and bacteriological study of bacterial folliculitis. Panacea Journal of Medical Sciences, 8(2), 54-58. https://doi.org/10.18231/2348-7682.2018.0014

Kuruvella, T., & Pandey, S. (2021). Tinea Barbae. StatPearls [Internet].

Lin, H. S., Lin, P. T., Tsai, Y. S., Wang, S. H., & Chi, C. C. (2018). Interventions for bacterial folliculitis and boils (furuncles and carbuncles). The Cochrane Database of Systematic Reviews, 2018(8), CD013099. https://doi.org/10.1002/14651858.CD013099

Ogunbiyi, A. (2019). Pseudofolliculitis barbae; current treatment options. Clinical, cosmetic and investigational dermatology, 12, 241–247. https://doi.org/10.2147/CCID.S149250

Singh, S., Sondhi, P., Yadav, S., & Ali, F. (2017). Tinea barbae presenting as kerion. Indian journal of dermatology, venereology, and leprology, 83(6). https://doi.org/10.4103/ijdvl.IJDVL_1104_16

SUBJECTIVE DATA:

Chief Complaint (CC): Presence of a rash that has blisters that starts from the chest radiating to the armpit and also on the patient’s back

History of Present Illness (HPI): William Mendel is a 30 year old Black African American who has a rash that is similar to blisters that has covered his chest and back radiating to the armpit. He states the onset of the onset of the rash was a week ago and at the site he has an itching sensation as well as him experiencing a burning pain and some tingling. He informs that the pain is at 8/10 and at palpation it’s at 10/10.

Medications:

Paracetamol over the counter two tablets every 6 hours for pain.
Diphenhydramine over the counter 25 mg 1 tablet thrice daily for the itching.
Hydrocortisone over the counter that is topical used when needed to also deal with the itching.
Flomax 0.4mg

Allergies:

The patient has no known food or drug allergies

Past Medical History (PMH):

1.) Gallstones

2.) Varicella Zoster Virus

3.) Chlamydia

Past Surgical History (PSH):

Kidney transplant 2008

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

Patient is a tee-tootler and a non-smoker. He also denies abusing any drugs. He enjoys outdoor activities and visiting the countryside. He also engages in swimming from time to time at the local river.

Immunization History:

Covid-19 Vaccine #2 4/8/2021 #2 8/10/2021 AstraZeneca

All his other vaccinations are up to date as per EPI guidelines

Significant Family History:

His parents are both dead due to natural reasons. He has three siblings who are alive. The sister however is diagnosed with asthma. The other two brother experience allergies during specific seasons such as in the spring.

Lifestyle:

The patient is newly married with only a few months having gone by. He is a business man in the import and exports sector. He however has a work- life stable lifestyle and as stated enjoys engaging in outdoor activities. He used to be a professional swimmer however he changed that and swims leisurely for now.

Review of Systems:

General: He denies experiencing any fatigue, loss of appetite or a fever. His complaint is the pain at the site of the rash.

HEENT: He also states he has had any head injury previously thus no visual issues.

nura 6512 lab assignment differential diagnosis for skin conditions — NURA 6512 Lab Assignment Differential Diagnosis for Skin Conditions

He has an excessive wax issue which he has seen an ENT specialist and is managing it. He however has no hearing loss issues, pain or tinnitus. For his nose he reports to nosebleed in extremely cold weather that is associated with the flu he gets in such environments. He denies any soreness of the throat, history of a cough or even a dry mouth.

Neck: There are no pain complaints or discomfort. There are also no distended jugular veins or swollen lymph nodes.

Breasts: There’s no discomfort tenderness nor drainage.

Respiratory: No dyspnea nor shortness of breath neither is there coughing or pain associated.

CV: No reports of dyspnea, palpitations, or chest pain when exerting oneself. Edema, syncope, rheumatic, claudication, or thrombophlebitis histories are not present. Electrocardiograms that were abnormal or negative for hypertension.

GI: Denies experiencing any diarrhea, constipation, diarrhea, nausea, or vomiting. Bowel patterns are normal every three days. No history of dyspepsia, food intolerance, rectal hemorrhage, hemorrhoids, or any of those things.

The patient’s gallbladder has previously been sick.

GU: no hematuria, penile pain or discharge, dysuria, testicular pain, or a history of hernias or UTI. The patient has a history of nocturia, frequent urination, a perception of incomplete bladder emptying, a strong need to urinate, and dribbling after urine. Abnormal patterns of ejaculation. Absence of STD history.

MS: He doesn’t have any complains of muscle or arthritis discomfort. Last year, I slipped and fell in the snow, but I wasn’t hurt or broke. Positive Range of motion in the upper and lower extremities, Trendelenburg gait

PSYCH: Disavows any feelings of sadness, suicidal or homicidal thoughts, anxiety, nightmares, hallucinations, or insomnia. Has a fear of clowns.

NEURO: Negative for headaches, tremors, numbness, weakness, or tingling. There were no vertigo, nausea, blackouts, seizures, or alterations in memory.

INTEGUMENT/HEME/LYMPH: Cluster and scattered rashes on the front and back of the chest. There are no further skin abnormalities.

ENDOCRINE: This region is normal. Currently no hormone therapy.

ALLERGIES/ IMMUNOLOGICAL: No known food or drug allergies and neither environmental nor immunological deficiencies.

OBJECTIVE DATA

PHYSICAL EXAM: B/P 156/90, left arm in a sitting position, regular adult cuff; P 82 and regular; T 98.9 orally; RR 18 and non-labored; PHYSICAL EXAM; Weight: 147 lbs., height: 5’6

General: Well-fed, alert, and talkative. Seems uneasy and is protecting the right upper torso.

HEENT: His head had no visual abnormalities. Neither a history of injuries nor headache symptoms.

Ten years ago, the patient underwent bilateral Lasik surgery, and there was no conjunctivitis. Hearing is not a problem, the ear canal is clear, and the tympanic membranes are pink with obvious land masks. No polyps or post-nasal drip were found. There is no throat inflammation, pain, or redness to speak of. Pink and wet oral mucosa is seen. The size and form of the tonsils are normal.

Lungs and chest: Symmetrical chest. No crackling or wheezing, just clean, equal lung sounds on auscultation throughout the entire lung area. Even and unlabored breathing is being done.

Heart/Peripheral Vascular: Systolic blood pressure in the 150s, slightly raised. Normal heartbeat and rhythm with S1 and S2 sounds absent of gallops or murmurs.

ABD: Abdomen soft, non-tender, and non-dilated with active bowel sounds present in all quadrants.

Genital/Rectal: External circumcision of the genitalia with no sores or scars.

No evidence of a hemorrhage.

Musculoskeletal: AROM to the upper and lower extremities is musculoskeletal. No prior fractures or trauma.

Right hip cannot be totally abducted.

Neuro: Responds to quarry age-appropriately. No unusual sensory or weak points were found.

Skin and lymph nodes: An open, fluid-filled blister is visible on the chest.

ASSESSMENT

LAB TESTS AND RESULTS:

SPO2: 94% with ambient air.

CBC: WBC: 8,000; RBC: 13

Polymerase Chain Reaction (PCR): 243.8

Differential Diagnosis:

Shingles;

Eczema;

Contact Dermatitis

DIAGNOSIS/CLIENT PROBLEM

Because the characteristic rash frequently does not emerge until after the discomfort begins, diagnosing shingles in its early stages can be challenging. Depending on the area of your body that is affected, additional causes such as an appendix infection (appendicitis), a gallbladder infection (cholecystitis), a slipped disk, or even a heart attack, may first be assumed.

Many persons who have shingles initially speculate that they may have an eczematous skin condition that is not communicable. They might believe they don’t need to see a doctor about it as a result, which could delay the diagnosis.

Primary Diagnoses:

1.) Eczema

References

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.

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.

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

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 (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.

By Day 7 of Week 4

Submit your Lab Assignment.

Submission and Grading Information

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Grading Criteria

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Week 4 Assignment 1 Rubric

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Submit your Week 4 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 4

To participate in this Assignment:

Week 4 Assignment 1

Week 4: Assessment of the Skin, Hair, and Nails

Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.

This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.

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Learning Objectives

Students will:

Apply assessment skills to diagnose skin conditions
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
Analyze dermatologic procedures to include skin biopsy, punch biopsy, suture insertion and removal, nail removal, skin lesion removal

Learning Resources

Required Readings (click to expand/reduce)

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.

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.

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