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Health Assessment Skin Condition
Advanced Health Assessment (NURS 6512)
Walden University
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Differential Diagnosis for Skin Conditions
Skin Condition Picture # 5
Patient Initials: AJ_ Age: 24_ Gender: F_
SUBJECTIVE DATA:
Chief Complaint (CC): Painful rash and joint pain
History of Present Illness (HPI): Anna James is a 24-year-old Caucasian female who presents today with a new onset of a painful plaque-like rash and joint pain 3 weeks ago. She reports she first noticed the rash on her knees and it has now developed on her elbows and scalp. She also reports that the rash is sore and slightly itchy. Anna has also noticed achy joints as well throughout the last 3 weeks. She reports that stressful situations seem to exacerbate the issue. She has changed laundry detergent and noticed no improvements in the rash, and she has also been taking Ibuprofen 400mg 3 times a day most days with little relief in pain. Anna reports the severity of her rash and joint pain to be 6/10.
Medications:
1 Over-the-Counter Ibuprofen 400mg PO every 6 hours as needed 2 Women’s Multivitamin 1 tablet PO daily 3 Ortho Tri-Cyclin 1 tablet PO daily
Allergies: No known drug or food allergies.
Past Medical History (PMH): 1 Varicella 2 Recurring tonsillitis 3 Appendicitis
Past Surgical History (PSH): 1 Tonsillectomy 2001 2 Appendectomy 2004
Sexual/Reproductive History: Heterosexual G0P0A Menarche at age 11 Patient reports regular menses Currently sexually active and has been on oral contraception regimen for 7 years Denies any risky sexual behavior Last Pap smear was in 2014 with normal results
Personal/Social History: Patient denies tobacco, ETOH, or illicit drug use. She states she exercises regularly and maintains a healthy diet.
Immunization History: Her immunizations are up to date. Her last Tdap was in 2010 and she has received her flu vaccine for this year. She does not meet criteria for receiving the pneumonia vaccination at this time.
Significant Family History: Mother, age 45, has history of breast cancer in 2007-currently in remission. Father, age 50, has history of eczema and multiple allergies. Maternal grandfather, age 71, has history of psoriasis and psoriatic arthritis. Paternal grandmother, age 73, has history of eczema and psoriasis. Two brothers aged 16 and 20 have recent history of fungal
Skin: Positive for sore, pruritic, polycyclic salmon-colored plaques located on the scalp, elbows, and knees bilaterally. Plaques are approximately 1 cm in size. Negative for pigment changes. Allergic/Immunologic: No known history of drug, food, or seasonal allergies. No known immunologic disorders.
OBJECTIVE DATA:
Physical Exam:
Vital signs: T- 97 tympanic; P- 82, regular; BP 112/68 right arm, sitting, regular adult cuff; RR- 17, non-labored; Pain 6/10; Ht: 5’7” Wt: 130 lbs BMI: 20 General: AAOx3. Well nourished, well groomed. No apparent distress. Appears uncomfortable. Normal gait. HEENT: PERRLA, EOMI, oronasopharnyx clear with no redness or swelling. Musculoskeletal: Symmetric muscle development, mild swelling of wrist, knee, and ankle joints bilaterally with pain present. Skin: Several areas of salmon-colored, silvery, polycyclic plaques located on the scalp, elbows, and knees, all about 1cm in size with discrete borders. Sore and slightly painful to palpation. No other rashes or cyanosis. Thick acrylic nails present, limiting nail assessment.
Lab Tests and Results: CBC- WBC 8,
Diagnostics: Skin biopsy- negative for fungal infection, positive for psoriasis.
ASSESSMENT:
Priority Diagnosis: Psoriasis
Differential Diagnoses: 1 Eczema 2 Lichen Planus 3 Mycosis Fungoides
When considering the patient’s symptoms and the description of the rash presented, it becomes quite clear that the patient is suffering from psoriasis. The strong family history of psoriasis and recent life stressors put the patient at a high risk for developing psoriasis (Ely & Stone, 2010). The patient’s complaint of joint pain also points toward a diagnosis of psoriasis, as the patient may be suffering from psoriatic arthritis, a complication of psoriasis. The description and location of the rash all point towards psoriasis as well (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Although Mycosis Fungoides presents in pink plaques, the differential diagnoses of Lichen Planus and Mycosis Fungoides can be ruled out after skin biopsy that reveals no fungal infection, as these conditions are both caused by fungi (Dains, Baumann, & Scheibel, 2016; Ely & Stone, 2010). Furthermore, Lichen Planus is characterized by a white plaque with net-like distribution, which is not found in the assessment (Ball et al., 2015). Eczema can be ruled out by the information provided and diagnostic testing, as well as the fact that plaques are not typically characteristic of eczema, unless there has been long-term scratching (Ball et al., 2015).
Skin Condition Picture # 2
Patient Initials: JM__ Age: 46 Gender: M
SUBJECTIVE DATA:
cigarettes/day x 30 years; drinks 5-10 beers/week; admits to regular marijuana use x 30 years. Patient does not have regular exercise habits but considers himself fairly active through outdoor work and occasional kayaking/hiking trips; his diet is regular and he admits is not healthy, mainly consisting of fried, fatty foods.
Immunization History: His last Tdap was in 2006 and he declines the Flu and Pneumonia vaccinations.
Significant Family History: Father- Atrial Fibrillation, Hypertension, Myocardial Infarction, Diabetes-Type 2, Dyslipidemia –died at age 68 of heart attack. Mother- Ischemic Stroke, Hypertension, Dyslipidemia-died at age 70 from complications of stroke. Siblings- two sisters with history of hypertension and diabetes-type 2, one with history of breast cancer in 2006. Children-all healthy with no medical issues
Lifestyle: He currently owns and operates his own pest control business and has for the past 15 years. He has been married once and has 4 children with his wife. They live in a suburban middle- class neighborhood with good transportation and school systems. He enjoys outdoor activities and often works on household issues in his free time. He has a strong support system through family and friends. He gets yearly check-ups for physical, vision, and dental health maintenance.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Negative for recent weight changes, fever, chills, night sweats, or changes in energy levels Respiratory: + for occasional productive cough with dark sputum in the mornings, denies any shortness of breath on exertion or exposure to tuberculosis Cardiovascular/Peripheral Vascular: Negative for chest pain, palpitations, edema, claudication, exercise intolerance. Gastrointestinal: + for heartburn; negative for nausea, vomiting, bowel changes Skin: + for ruby red papular rash on trunk, denies pruritus, pain, eruptions, or pigmentation changes. Hematologic: + for prolonged bleeding times and easy bruising, negative for anemia Allergic/Immunologic: + for drug allergies to penicillin and sulfa drugs, bees. Denies any recent new drug use. No current issues.
OBJECTIVE DATA:
Physical Exam: Vital signs: T- 98 oral; P- 72, irregular; BP- 128/72 left arm, sitting, long cuff; RR- 18; Pain 0/10 Ht: 6’2” Wt: 210 lbs BMI: 27
General: AAO x3, moves all extremities, gait normal, well developed, well nourished, not malodorous. Appears comfortable and not in any apparent distress. Chest/Lungs: Breath sounds clear and equal AP&L bilaterally Heart/Peripheral Vascular: Irregular rhythm, controlled rate. No murmur, rub, or gallop. Pulses +2 bilateral radials and +2 bilateral pedals. Abdomen: Bowel sounds present x4 quadrants. Soft, non-tender, non-distended. No organomegaly. Skin: Ruby red papular rash on the trunk with no itching or pain present. No edema, clubbing, or cyanosis. No palpable nodules.
R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. Ely, J. W., & Stone, M. S. (2010). The generalized rash: Part I. Differential diagnosis. American Family Physician, 81(6), 726-734. Retrieved from aafp/afp/2010/0315/p726.html
Health Assessment Skin Condition
Course: Advanced Health Assessment (NURS 6512)
University: Walden University
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