Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512N
Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512N
Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512N
OBJECTIVE DATA
PHYSICAL EXAM: Blood pressure- 124/80, right arm in a sitting position, regular adult cuff; Pulse- 88 and regular; Temperature -94.6 orally; Respiration rate- 24 and non-labored; PHYSICAL EXAM; Weight: 164 lbs., height: 5’9
General: Patient is alert and oriented responding to assessment questions appropriately.
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HEENT:
On inspection head normocephalic, on pupils assessment they were normal reactive, on otoscope assessment auditory ear canals were without erythema, on inspection of nose no discharge or polyps, on inspection of neck no deformities noted, on palpation neck has full range of motion and thyroid WNL.
Lungs and chest: On inspection of chest it was symmetric without scars, on palpation of chest no tenderness noted, on auscultation of chest normal lung sounds noted.
Heart/Peripheral Vascular: S1 and S2 heard on auscultation, blood pressure is normotensive, normal heart rhythm, normal heart rate.
ABD: On inspection no scars noted, on auscultation bowel sounds were normoactive and on palpation no masses detect.
Genital/Rectal: Normal external genitalia observed
Musculoskeletal: On inspection no deformity noted on the back, on percussion spin is non-tender, on palpation of muscles no spasms noted.
Neuro: Patient on assessment of cranial nerves II-XII they were found to be intact, patient had normal range of motion and sensory tests revealed senses were grossly intact.
Skin and lymph nodes: On inspection of patient’s beard inflamed reddish nodule with pustules observed. On palpation the nodules were tender. On palpation of neck lymph nodes were slightly palpable.
ASSESSMENT
LAB TESTS AND RESULTS:
SPO2: 98%.
Wood lamp examination: dull blue organisms observed
Skin biopsy: to reveal presence of lymphocytes and neutrophils
Lab culture: fungal elements identified
Differential Diagnosis:
- Tinea barbae; this is a fungal condition that can affect the beard region and presents with red, itchy, inflamed patches consistent with the patient’s clinical manifestations. Additionally, the findings indicated fungal elements consistent with this condition (Kuruvella & Pandey, 2020).
- Impetigo; this is a condition that affects the skin presenting with clinical manifestations such as red sores and even blisters that can even occur at the beard region consistent with the patient’s signs and symptoms. However, the condition brings about a honey colored crust that the patient did not present with (Johnson, 2020).
- Seborrheic dermatitis; this is another condition that affects the skin that presents with redness, itching and scaling similar to the patient’s clinical manifestations. However this is a bacterial condition and the findings are indicative that the patients disease is fungal related due to presence of fungal elements (Tucker & Masood, 2019).
Primary Diagnoses:
1.) Tinea barbae
References
Johnson, M. K. (2020). Impetigo. Advanced Emergency Nursing Journal, 42(4), 262-269.
Kuruvella, T., & Pandey, S. (2020). Tinea Barbae.
Tucker, D., & Masood, S. (2019). Seborrheic dermatitis.
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 (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
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK4Assgn1+last
name+first initial.(extension)” as the name. - Click the Week 4 Assignment 1 Rubric to review the Grading Criteria for the
Assignment. - Click the Week 4 Assignment 1 link. You will also be able to “View Rubric” for grading
criteria from this area. - Next, from the Attach File area, click on the Browse My Computer button. Find the
document you saved as “WK4Assgn1+last name+first initial.(extension)” and
click Open. - If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit
my paper(s) to the Global Reference Database. - Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 4 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
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
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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.
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.
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. - Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.
Chapter 2, "The Comprehensive History and Physical Exam" (Previously
read in Weeks 1 and 3)
VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from
http://www.skinsight.com/info/for_professionals
This interactive website allows you to explore skin conditions according to
age, gender, and area of the body.
- Clothier, A. (2014). Assessing and managing skin tears in older people.
Nurse Prescribing, 12(6), 278–282.
Document: Skin Conditions (Word document)
This document contains five images of different skin conditions. You will
use this information in this week’s Discussion.
- Document: Comprehensive SOAP Exemplar (Word document)
- Document: Comprehensive SOAP Template (Word document)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
- Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY - Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us - Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF) - Document: Shadow Health Nursing Documentation Tutorial (Word
document) - Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Health
History (Word document)
Use this template to complete your Assignment 2 for this week.
Optional Resources
- LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 6, “The Skin and Nails”
In this chapter, the authors provide guidelines and procedures to aid in the
diagnosis of skin and nail disorders. The chapter supplies descriptions and
pictures of common skin and nail conditions.
- Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from
https://web.archive.org/web/20170215015223/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/a
bsorbable_suture_chart.pdf - Ethicon, Inc. (2006). Dermabond topical skin adhesive application
technique. Retrieved from
https://web.archive.org/web/20150921174121/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/d
b_application_poster.pdf - Ethicon, Inc. (2001). Ethicon needle sales types. Retrieved from
https://web.archive.org/web/20150921171922/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/n
eedle_template.pdf - Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from
https://web.archive.org/web/20150921202525/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/s
uture_chart_ethicon.pdf - Ethicon, Inc. (2002). How to care for your wound after it's treated with
Dermabond topical skin adhesive. Retrieved from
https://web.archive.org/web/20150926002534/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/d
b_wound_care.pdf - Ethicon, Inc. (2005). Knot tying manual. Retrieved from
https://web.archive.org/web/20160915214422/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/k
not_tying_manual.pdf - Ethicon, Inc. (n.d.-c). Wound closure manual. Retrieved from
https://web.archive.org/web/20170829043048/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/et
h
Required Media (click to expand/reduce)
Module 3 Introduction
Dr. Tara Harris reviews the overall expectations for Module 3. Consider how you will manage your time as you review your media and Learning Resources for your Discussions, Case Study Lab Assignments, DCE Assignments, and your Midterm exam (12m).
Accessible player
Online media for Seidel's Guide to Physical Examination
In addition to this week's media, it is highly recommended that you access and view the online resources included with the text, Seidel's Guide to Physical Examination. Focus on the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and nails.
Note: To access the online resources included with the text, you need to complete the FREE online registration that is located at https://evolve.elsevier.com/cs/product/9780323172660?role=student .
To Register to View the Content
1. Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student
2. Enter the name of the textbook, Seidel's Guide to Physical Examination (name of text without the edition number) in the Search textbox.
3. Complete the registration process.
To View the Content for this Text
1. Go to https://evolve.elsevier.com/
2. Click on Student Site.
3. Type in your username and password.
4. Click on the Login button.
5. Click on the plus sign icon for Resources on the left side of the screen.
6. Click on the name of the textbook for this course.
7. Expand the menu on the left to locate all the chapters.
8. Navigate to the desired content (checklists, videos, animations, etc.).
Note: Clicking on the URLs in the APA citations for the Resources from
the textbook will not link directly to the desired online content. Use the
online menu to navigate to the desired content.
Suturing Tutorials
The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques.
Tulane Center for Advanced Medical Simulation & Team Training. (2010, July 8). Suturing technique [Video file]. Retrieved from https://www.youtube.com/watch?v=c-LDmCVtL0o
Note: Approximate length of this media program is 5 minutes.
Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical mattress, horizontal mattress [Video file]. Retrieved from https://www.youtube.com/watch?v=MFP90aQvEVM
Note: Approximate length of this media program is 9 minutes. Incision and Drainage of an Abscess (a common procedure in primary
care)
New England Journal of Medicine (NEJM). (2013, September 30). NEJM abscess incision and drainage [Video file]. Retrieved from https://www.youtube.com/watchv=MwgNdrA18fM&list=PL9UKTUFtRDcN
q4–Vf2NYfUANEyObfeNm&index=8
Note: Approximate length of this media program is 10 minutes.
Dermablade Use for Shave Biopsies Dermablade®. (2012, November 9). PersonnaBlades [Video file]. Retrieved from https://www.youtube.com/watch?v=D8u1Y18L9DQ
Note: Approximate length of this media program is 5 minutes.
SUBJECTIVE DATA:
Chief Complaint (CC): “Stretch marks.” (Image 2)
History of Present Illness (HPI): W.T. is a 26-year-old AA female presenting to the dermatologic clinic with complaints of stretch marks. She is concerned about her appearance and wishes to know if there is any cream she can use to reduce the appearance of stretch marks. She is pregnant, and the gestation by date (GBD) is 32 weeks. The stretch marks began appearing when she was about 22 weeks pregnant, and they have increased in number and size as the pregnancy progressed. She reports having used cocoa butter, shea butter lotions, and various stretch marks creams, but they have been ineffective.
Medications: Iron and Folic acid Supplements
Allergies: Allergic to Penicillin- causes a rash.
Past Medical History (PMH): No chronic illnesses.
Past Surgical History (PSH): Tonsillectomy at 6 years.
Sexual/Reproductive History: Para 0+0, Gravida-1; No history of STIs or gynecological disorders. Had UTI at 16 weeks GBD but was successfully treated with Nitrofurantoin. She was previously on IUD.
Personal/Social History: W.T. is married and lives with her husband in Baltimore, MD. She has a Diploma in Secretarial studies and works as a corporate secretary. Her hobbies are baking and traveling. She reports having about six small meals and about 3L of water daily. She used to smoke ½ PPD and drink 2-3 glasses of vodka on her off days before getting pregnant. She denies currently taking alcohol, smoking, or using any drug substances. The patient states that her husband and elder sister are her support system.
Health Maintenance: The patient reports attending antenatal checkups and adheres to the daily Iron and Folic Acid supplements.
Immunization History: Her immunization status is up to date. She had a TT2 booster in the last antenatal visit. The last Flu shot was 8 months ago.
Significant Family History: The maternal grandmother has Rheumatoid arthritis and HTN. The father was recently diagnosed with diabetes. Her siblings are alive and well.
Review of Systems:
General: Denies fever, generalized weakness, or chills.
HEENT: Denies eye redness, excessive tearing, blurred vision, nasal secretions, or swallowing difficulties.
Respiratory: Denies breathing difficulties, wheezing, or coughing.
Cardiovascular/Peripheral Vascular: Denies edema, chest tightness, palpitations, or exertional dyspnea.
Gastrointestinal: Reports occasional nausea and vomiting. Denies abdominal pain, heartburn, diarrhea, or constipation.
Genitourinary: Reports urine frequency and increased PV discharge. Denies foul-smelling discharge, lower abdominal pain, or urinary urgency.
Musculoskeletal: Denies back pain, joint stiffness, or pain.
Neurological: Negative for headaches, dizziness, or muscle weakness.
Psychiatric: Negative for psychotic, mood, or anxiety symptoms.
Skin/hair/nails: Reports stretch marks. Denies itching, burning sensation, rashes, bruising, or brittle nails
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP-122/78; HR-80; RR-16; Temp-98.4; HT-5’4; WT- 154 lbs.
General: AA female client in no distress. She is alert and oriented x3.
HEENT: Head is symmetrical; Eyes: Sclera is white; Conjunctiva is pink; PERRLA; Ears: Intact and shiny TMs
Neck: Symmetrical and Supple. Thyroid gland normal on palpation.
Chest/Lungs: Uniform chest expansion. Smooth respirations; Lungs clear on auscultation.
Heart/Peripheral Vascular: No edema or neck vein distension. Regular heart rate and rhythm; S1 and S2 present; No murmurs.
Abdomen: Gravid abdomen; The abdominal skin is stretched with marked striae. Linea nigra present; Normoactive BS; FHR-142b/min; Gravid mass on palpation; No tenderness on palpation; No organomegaly.
Genital/Rectal: Normal female genitalia. Intact anal sphincter.
Musculoskeletal: Active ROM; No joint deformities.
Neurological: Clear speech; CNs are intact; Muscle strength- 5/5; Upright posture; Steady gait.
Skin: Flat dark streaks on the abdomen. The dark streaks are raised, 1-10 mm wide, and the length varies at 1-5 cm. A dark vertical line runs from the diaphragm to the pubic area.
Diagnostic results: No tests were ordered.
ASSESSMENT:
Striae gravidarum: Striae gravidarum are stretch marks that appear during pregnancy. They are caused by thin tears in the dermal collagen. They appear as flat red or hypopigmented stripes that become raised, longer, wider, and violet-red (Abbas et al., 2018). The patient has dark flat streaks on the abdomen that first occurred during pregnancy, which align with Striae gravidarum.
Anetoderma: It is characterized by flaccid, well-circumscribed areas of slack skin. Sac-like protrusions can sometimes be observed in some lesions. It is attributed to the loss of elastic fibers within the dermis (Genta et al., 2020). Histopathology is necessary to confirm or rule out Anetoderma to determine if elastic tissue is lost in the dermis.
Lichen sclerosus: This is a rare autoimmune skin condition characterized by skin atrophy and hypopigmentation. It commonly affects genital skin. It typically begins as a sharply demarcated erythema that progresses into thin, hypopigmented, ivory-white, and sclerotic plaques. The plaques are surrounded by a purple, red, or violet border (Singh & Ghatage, 2020). The hypopigmented streaks make this a differential diagnosis. However, the patient has no plaques, and the streaks are not in the genital area ruling Lichen sclerosus as the primary diagnosis.
Elastotic striae: This is a rare skin condition that manifests as asymptomatic atrophic yellow lines on the thighs, mid or lower back, arms, or breasts. It manifests clinically with asymptomatic, numerous, yellowish, elevated, irregularly indurated, striae-like lines or bands spread horizontally across the lower and middle part of the posterior trunk (Palaniappan et al., 2023). The patient has raised irregular streaks, but they are not in the posterior trunk, making this an unlikely primary diagnosis.
Scarring: Scars present as raised, firm nodules or plaques, usually at sites of previous trauma (Barone et al., 2021). However, the patient has no history of abdominal trauma, which rules out scarring as the cause of the hypopigmented streaks.
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Abbas, A. M., Kamel, F. M., & Salman, S. A. (2018). Clinical significance and treatment of striae gravidarum during pregnancy: a review article. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 8(1), 368. doi:10.18203/2320-1770.ijrcog20185454
Barone, N., Safran, T., Vorstenbosch, J., Davison, P. G., Cugno, S., & Murphy, A. M. (2021). Current Advances in Hypertrophic Scar and Keloid Management. Seminars in plastic surgery, 35(3), 145–152. https://doi.org/10.1055/s-0041-1731461Lokhande, A. J., & Mysore, V. (2019). Striae Distensae Treatment Review and Update. Indian dermatology online journal, 10(4), 380–395. https://doi.org/10.4103/idoj.IDOJ_336_18
Genta, M. P., Abreu, M. A. M. M., & Nai, G. A. (2020). Anetoderma: an alert for antiphospholipid antibody syndrome. Anais brasileiros de dermatologia, 95(1), 123–125. https://doi.org/10.1016/j.abd.2019.04.010
Palaniappan, V., Selvaarasan, J., Murthy, A. B., & Karthikeyan, K. (2023). Linear focal elastosis. Clinical and Experimental Dermatology, 48(3), 175-180. https://doi.org/10.1093/ced/llac071
Singh, N., & Ghatage, P. (2020). Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review. Obstetrics and gynecology international, 2020, 7480754. https://doi.org/10.1155/2020/7480754
NURS_6512_Week_4_Assignment_1_Rubric
| NURS_6512_Week_4_Assignment_1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeUsing the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic. |
| 35 pts | ||||
| This criterion is linked to a Learning Outcome· Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature. |
| 50 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
| 5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
| 5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
| 5 pts | ||||
| Total Points: 100 | ||||||
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