NURS 6512 Week 4 Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions Sample Essay
Allergic Rhinitis: The patient’s primary differential diagnosis is allergic rhinitis. As previously stated, allergic rhinitis is a respiratory condition brought on by allergen exposure. Itchy eyes, rhinorrhea, nasal congestion, and sneezing are all symptoms of allergic rhinitis. The symptoms were caused by allergic reactions to allergens mediated by IgE. (Okubo et al., 2020). Allergy rhinitis is the most likely diagnosis based on the patient’s positive skin test.
Another condition that could be affecting the customer is non-allergic rhinitis. Itchy eyes, nasal congestion, and rhinorrhea are common complaints among patients. Patients, on the other hand, have never previously experienced an allergic reaction to an allergen (Zheng Ming et al., n.d.). In the case study, this is the least likely diagnosis for the client.
Sinusitis is an inflammatory condition that affects the paranasal sinuses. Allergic reactions, viral, bacterial, and fungal infections are some of the causes of sinusitis. Patients with sinusitis experience symptoms such as facial pain, fever, headache, and rhinorrhea (Little et al., 2018). Sinusitis, on the other hand, is the least likely condition due to the lack of infection-related signs and symptoms.
A common cold or the flu is another possible diagnosis. The common cold is a severe viral infection of the upper respiratory tract. It may cause laryngeal, throat, or sinus problems. Patients have reported headaches, fevers, malaise, and nasal discharge as symptoms. Despite the absence of infection-related symptoms, it is the least likely (Sadeghirad et al., 2017).
A sore throat is another possible diagnosis for the patient. Patients experience pharyngeal pain when swallowing. Sore throats are caused primarily by viral infections. However, because there are no infection symptoms or signs, the patient is unaffected by a sore throat (Mahalingam et al., 2020).
Patient Information: R.S, 50-year-old male
CC: Nasal congestion as well as itching for the last 5 days
HPI: R.S is a 50-year-old male that came to the unit with complaints of nasal congestion, rhinorrhea, sneezing, itchy nose, postnasal discharge, and itching ears and nose for the last 5 days. The patient reported using Mucinex medication to help ease breathing but it has been associated with minimal effectiveness. The patient denied any history of pain or headache.
Medications: The patient currently uses Mucinex over-the-counter medication 1 tab orally on a daily basis.
Allergies: The patient denied any history of drug or food allergy. The patient reported history of seasonal allergies.
PMHx: The patient denied history of hospitalization, surgery, and blood transfusion. The immunization history of the client is up to date.
Social Hx: The patient is married with two children. The patient stopped smoking in 2012. He drinks alcohol on occasional basis. His highest level of education is university. He has a degree in business
administration and works at a local supermarket as a manager. He reported to engage in active physical activity. He reported that the symptoms of the disease had affected his sleeping patterns significantly.
Family Hx: The parents of the patient are both alive. His father was diagnosed with diabetes in 2016 and has been on treatment. His mother was diagnosed with hypertension in 2020 and is on treatment. The patient is the second born in a family of three. His siblings are all alive and healthy.
General: The patient appeared well groomed for the occasion. He was oriented to time, place, and self. He denied fevers, fatigue, or chills. The patient reported being tired due to lack of enough sleep secondary to the symptoms of the health problem.
HEENT: The patient denied headaches. The patient reported that his eyes are itchy and red. There were no changes in the vision. The tympanic membranes are intact, with absence of ear drainage of changes in hearing. The patient reported nasal congestion, itchy, with pale and boggy nasal mucosa. There was clear nasal drainage with slightly enlarged nasal turbinates. There was absence of tonsillitis. The throat was mildly erythematous.
Neck: The trachea was midline without any deviation or lymphadenopathy.
Skin: The patient denied skin rash, changes in skin color, and itching.
Cardiovascular: The patient denied chest pain, palpitations, discomfort, or edema.
Respiratory: The patient denied shortness of breath, cough or difficulty in breathing
Musculoskeletal: The patient denied joint or muscle pain.
Lymphatic: The client denied lymphadenopathy
Allergies: The client denied any known food or drug allergy. He reported seasonal allergies.
HEENT: The patient reports that his eyes are itchy. The eyes appear red. The tympanic membranes are intact with the absence of any drainage. The nasals are congested, with boggy, pale mucosa and inflamed nasal turbinates. There is the evidence of drainage of thin, clear secretion. There is mild erythema on the throat with absence of tonsillitis and bleeding.
The skin test revealed a positive reaction to pollen. The results showed that the patient has allergic rhinitis. Allergic rhinitis is a condition of the upper respiratory system that arises from an individual exposure to an allergen. Patients experience symptoms that include sneezing, rhinorrhea, itchy nose and eyes, nasal congestion, and sore throat among others. Diagnostic investigations are not recommended in allergic rhinitis since they do not have any cost benefits. Healthcare providers can utilize history taking and physical examination to diagnose patients with the condition. It is however important to perform tests such as skin tests to determine whether a patient has allergic rhinitis in people without history of allergic reactions.
Little, R. E., Long, C. M., Loehrl, T. A., & Poetker, D. M. (2018). Odontogenic sinusitis: A review of the current literature. Laryngoscope Investigative Otolaryngology, 3(2), 110–114. https://doi.org/10.1002/lio2.147
Mahalingam, N. V., Abilasha, R., & Kavitha, S. (2020). Awareness of symptomatic differences COVID-19, sars, swine flu, common cold among dental students. International Journal of Research in Pharmaceutical Sciences, 11(Special Issue 1). https://doi.org/10.26452/ijrps.v11iSPL1.3431
Okubo, K., Kurono, Y., Ichimura, K., Enomoto, T., Okamoto, Y., Kawauchi, H., Suzaki, H., Fujieda, S., Masuyama, K., & Allergology, T. J. S. of. (2020). Japanese guidelines for allergic rhinitis 2020. Allergology International, 69(3), 331–345. https://doi.org/10.1016/j.alit.2020.04.001
Sadeghirad, B., Siemieniuk, R. A. C., Brignardello-Petersen, R., Papola, D., Lytvyn, L., Vandvik, P. O., Merglen, A., Guyatt, G. H., & Agoritsas, T. (2017). Corticosteroids for treatment of sore throat: Systematic review and meta-analysis of randomised trials. BMJ, 358, j3887. https://doi.org/10.1136/bmj.j3887
Zheng Ming, Wang Xiangdong, Ge Siqi, Gu Ying, Ding Xiu, Zhang Yuhuan, Ye Jingying, & Zhang Luo. (n.d.). Allergic and Non-Allergic Rhinitis Are Common in Obstructive Sleep Apnea but Not Associated With Disease Severity. Journal of Clinical Sleep Medicine, 13(08), 959–966. https://doi.org/10.5664/jcsm.6694
Skin Comprehensive SOAP Note
This SOAP NOTE will focus on image #1.
Patient Initials: AD Age: 34 Gender: Male
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.
Allergies: No known drug or food allergies.
Past Medical History (PMH):
Past Surgical History (PSH):
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.
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.
AD presents annually for a routine physical exam. He reports bloodwork 2 years ago at an annual exam.
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.
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.
- 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.
- Median nail dystrophy
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.
Skin Comprehensive SOAP Note
Patient Initials: B.B Age: 32 years Gender: Male
Chief Complaint (CC): “Red patches on the beard with pus-filled pimples.” (Graphic 3)
History of Present Illness (HPI):
B.B is a 32-year-old White male with chief complaints of having red patches on the beard with pus-filled pimples. He states that the patches are on the left side of the lower beard. The patches started as acne papules about ten days ago, which later turned yellow and pus-filled. The pimples begin as papules and progress to pustules, which have proliferated over the days. The client reports that the part with the red patches is tender to touch. Besides, he experiences a mild itching sensation, and some hair plucks when he scratches the beard. He states that the beard hair on and around the red patch is brittle and lusterless. The patient mentions that he bought OTC Betamethasone cream four days ago to alleviate the itchiness and eliminate the pimples, but it has not had any effect.
Medications: OTC Betamethasone cream.
Allergies: Allergic to Sulphur- causes a rash.
Past Medical History (PMH): History of Asthma- diagnosed at 6 years. Last exacerbation at 25 years.
Past Surgical History (PSH): None
Sexual/Reproductive History: Denies history of STIs.
B.B is married and lives with his spouse and two children aged 5 and 2 years. He has a Bachelor’s in Mass Communication and works as an editor in a publishing company. He reports taking 3-4 glasses of whiskey on his day offs but denies smoking or using drug substances. His hobbies include playing basketball and reading fictional novels. He is the captain of the basketball team in his organization and coaches the basketball team in the local high school in his free time. He reports sleeping 6-7 hours daily and eating 4-5 healthy meals daily.
Health Maintenance: The patient goes to the gym 3-4 days a week. He plays basketball on weekends. He reports attending annual wellness exams.
Last Tdap- 07/2015
Influenza shot- 06/2022
COVID-19 vaccine- 03/2021 (1st dose) 05/2021 (2nd dose) AstraZeneca
Significant Family History:
The paternal great-grandfather had HTN and died from stroke at 92 years. His maternal grandmother has DM and rheumatoid arthritis. His Father has controlled HTN, diagnosed at 54 years. Siblings and children are alive and well.
Review of Systems:
General: Negative for weight changes, fever, chills, or fatigue.
HEENT: Negative for headache, double/blurred vision, excessive lacrimation, ear pain/discharge, hearing loss, nasal secretions, sneezing, or throat pain.
Respiratory: Denies cough, sputum, chest pain, or breathing difficulties.
Cardiovascular/Peripheral Vascular: Negative for lower limbs edema, palpitations, chest pain, increased fatigue, or dyspnea on exertion.
Gastrointestinal: Negative for nausea, vomiting, regurgitation, epigastric/abdominal pain, rectal bleeding, or diarrhea/constipation.
Genitourinary: Negative for blood in urine, dysuria, urinary frequency, or urgency.
Musculoskeletal: Negative for joint pain/stiffness, muscle pain, or lower back pain.
Neurological: Denies headaches, dizziness, black spells, or tingling sensations.
Psychiatric: Denies having depressive, anxiety, obsessive symptoms, or suicidal thoughts.
Skin/hair/nails: Positive for mild itching on the lower left beard area. Pus-filled pimples on the beard and red skin patches. Brittle beard hair.
Vital signs: BP-110/68; HR- 72; RR- 16; Temp-98.2 Ht-5’7; Wt-171 lbs.
General: The client is calm, alert, and oriented. He is well-groomed and displays positive body language. He maintains eye contact and has a positive attitude towards the clinician.
HEENT: Head is symmetrical and normocephalic. Eyes: Sclera is white, and conjunctiva is pink, PERRLA. Ears: Tympanic membranes are shiny and intact. Nose: The nasal septum is intact. Throat- Tongue is pink and midline; No tooth cavities, and the Tonsillar gland is non-erythematous.
Neck: Full ROM; Trachea is well-aligned.
Chest/Lungs: Uniform and smooth respirations. The chest is clear.
Heart/Peripheral Vascular: No edema or jugular vein distention. S1 and S2 are present. No gallop sound or systolic murmur.
Abdomen: The abdomen is flat and moves with respirations. Bowel sounds are normoactive. No abdominal tenderness, masses, organomegaly, or guarding.
Genital/Rectal: Normal male genitalia. Rectal sphincter is intact.
Musculoskeletal: Full ROM in all joints; No fractures, enlarged joints, or joint tenderness/stiffness.
Neurological: Muscle strength- 5/5. Normal gait, balance, and posture.
Skin: Fair, warm, and dry skin with normal turgor. The skin at the lower left beard is inflamed with red lumpy patches. Yellow pustules and crusting on the beard involve the hair root and follicle. Broken beard hairs on the red patches.
Diagnostic results: No diagnostic results are available.
Tinea Barbae: Tinea barbae is a dermatophyte infection occurring in the beard area. It is characterized by superficial annular lesions. However, some patients can present with a deeper infection that resembles folliculitis (Walkty et al., 2020). Tinea barbae can also be an inflammatory kerion that causes scarring hair loss. It is typically inflamed with red lumpy areas, pustules, and crusting around the hairs. The hairs can be plucked out easily. Mild itching, irritation, or pain is often present (Walkty et al., 2020). Tinea barbae is the primary diagnosis based on positive findings of patchy red areas in the beard area with pustules and mild irritation. The brittle and easily plucked-out beard hairs also support the diagnosis.
Pseudofolliculitis Barbae: This is an irritation of the skin caused by hairs that penetrate the skin before coming out of the hair follicle or come out of the follicle and curve back into the skin, resulting in a foreign-body reaction (Ogunbiyi, 2019). Pseudofolliculitis barbae mostly occurs around the beard and neck. Clinical manifestations include an erythematous papule with a hair shaft at the center (Ogunbiyi, 2019). Pseudofolliculitis barbae is a differential diagnosis based on the pustule and erythematous patches in the patient’s lower beard.
Bacterial Folliculitis: This is a bacterial infection of hair follicles. It is mostly caused by Staphylococcus aureus, but occasionally Pseudomonas aeruginosa. Clinical manifestations include mild pruritus, pain, or irritation (Jappa & Sameer, 2018). Physical findings include a superficial pustule or inflammatory nodule around a hair follicle. The infected hairs fall out or are plucked by the patient, but new papules develop (Jappa & Sameer, 2018). The growth of stiff hairs into the skin may result in chronic low-grade inflammation or irritation. Bacterial Folliculitis is a differential based on positive symptoms of mild pruritus, papules that progress to pustules on the beard area, and beard hair that easily plucks off.
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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
Ogunbiyi, A. (2019). Pseudofolliculitis barbae; current treatment options. Clinical, cosmetic and investigational dermatology, pp. 12, 241–247. https://doi.org/10.2147/CCID.S149250
Walkty, A., Elgheriani, A., Silver, S., Pieroni, P., & Embil, J. (2020). Tinea barbae presenting as a kerion. Postgraduate Medical Journal, 96(1137), 441-441. http://dx.doi.org/10.1136/postgradmedj-2020-137609