NURS_6512 DIFFERENTIAL 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.

  • 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.

For the skin condition I choose the cellulitis from the pictures (diagram #4) Week_4_NURS_6512_Week04_skinConditions.doc

 

Answer

Skin Comprehensive SOAP Note

Patient Initials: A.B_ Age: __42_ Gender: __Male Race: White American

SUBJECTIVE DATA:

Chief Complaint (CC): “Painful swelling and redness in my left lower leg.”

History of Present Illness (HPI): Mr. A.B., a 42-year-old White American male, presents to the hospital with a chief complaint of painful swelling and redness in his left lower leg. He reports that the symptoms began two days ago and have progressively worsened. The patient notes that he initially noticed a small red spot on his leg, which has since expanded and become increasingly painful. There is no specific history of trauma or injury to the affected area. The patient describes the pain as a constant throbbing sensation and rates it as 7 out of 10 on the pain scale. He reports difficulty walking due to the swelling and tenderness in the affected leg. The patient has tried over-the-counter pain relievers, but they provided minimal relief.

Medications:

  1. Metformin 500 mg orally once daily.
  2. Amlodipine 5 mg orally once daily.
  3. Hydrochlorothiazide 25 mg orally once daily.

Allergies: No known food or drug allergy

Past Medical History (PMH): He was diagnosed with hypertension in 2020 and had been taking Amlodipine 5 mg orally once daily and Hydrochlorothiazide 25 mg orally once daily as part of his antihypertensive regimen. In addition, he was diagnosed with diabetes two years ago and has been prescribed Metformin 500 mg orally once daily to manage his blood sugar levels.

Past Surgical History (PSH): No surgical history

Sexual/Reproductive History: Mr. A.B. states that he engages in heterosexual intercourse and has never undergone any reproductive procedures or surgeries. He denies any history of sexually transmitted infections (STIs) or known fertility issues. He mentions having two children with his current partner, both conceived naturally. He denies concerns about erectile dysfunction, premature ejaculation, or difficulty achieving orgasm.

Personal/Social History: The patient lives with his wife and two children in a modern apartment equipped with advanced technology in a suburban area with a low crime rate and good public transportation. He is a software engineer working in a sedentary role for a prominent technology company with comprehensive medical insurance. The patient admits to being a former smoker, having quit approximately three years ago when he was diagnosed with hypertension, but does not consume alcohol or recreational drugs.

Health Maintenance: His physical activity is limited due to his desk job, although he mentions occasional leisure activities such as hiking and swimming.

Immunization History: Mr. A.B. is compliant with all immunizations. The last one is the Covid-19 vaccine booster he received in September of last year.

Significant Family History: The family history is notable for hypertension in his father and diabetes in his maternal grandmother. His paternal grandfather succumbed to cellulitis a year ago.

Review of Systems:

General: The patient complains of localized redness, warmth, and swelling in the affected area. He reports feeling fatigued and has a mild fever of 100.4°F (38°C). No recent weight loss or changes in appetite.

HEENT: The patient denies significant head trauma, headache, dizziness, or visual disturbances. He reports no ear pain, tinnitus, or hearing loss. No nasal congestion, sneezing, or sinus pressure. No sore throat, difficulty swallowing, or oral lesions. No dental issues or changes in taste.

Respiratory: The patient denies shortness of breath, cough, wheezing, or chest pain. No history of chronic cough or respiratory infections. No sputum production or blood in the phlegm. No exposure to environmental pollutants or occupational hazards.

Cardiovascular/Peripheral Vascular: The patient reports no chest pain, palpitations, or irregular heartbeats.

Gastrointestinal: The patient reports no abdominal pain, nausea, vomiting, or changes in bowel movements.

Genitourinary: The patient reports no urinary frequency, urgency, or burning sensation. No hematuria, cloudy urine, or difficulty initiating or stopping urination. No history of kidney stones or urinary tract infections. No erectile dysfunction or changes in libido.

Musculoskeletal: The patient reports pain, tenderness, and swelling in the affected area. No joint pain, stiffness, or limited range of motion. No history of fractures, dislocations, or chronic musculoskeletal conditions. No muscle weakness or abnormal gait.

Neurological: The patient denies any headaches, seizures, or changes in sensation. No numbness, tingling, or weakness in the extremities. No balance or coordination issues. No history of neurological disorders or previous strokes.

Psychiatric: The patient reports no symptoms of depression, anxiety, or mood swings. No changes in sleep patterns or appetite. No history of psychiatric disorders or suicidal thoughts. No difficulty concentrating or memory loss.

Skin/hair/nails: The patient reports no recent skin rashes, itching, or hives. No hair loss or changes in nail color or texture. No history of skin infections or chronic skin conditions.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Blood Pressure: 130/80 mmHg, Heart Rate: 82 beats per minute, Respiratory Rate: 18 breaths per minute, and Temperature: 100.4°F (38°C) (oral).

General: Mr. A.B. appears mildly uncomfortable, favoring his left leg while walking. He is well-groomed and appropriately dressed for the weather. He maintains good eye contact and appears cooperative during the examination.

HEENT: The head is normocephalic and atraumatic. The patient’s eyes are clear and symmetrical, with no signs of redness, discharge, or vision changes. Ears, nose, and throat appear normal without pain, swelling, or discharge.

Neck: Neck is supple with no palpable lymphadenopathy.

Chest/Lungs: Auscultation reveals bilateral breath sounds, with no wheezing or crackles.

Heart/Peripheral Vascular: Heart sounds are regular with no murmurs, rubs, or gallops. Peripheral pulses are palpable and symmetric in all extremities. There are no signs of cyanosis.

Abdomen: There is no tenderness or distension on palpation of the abdomen.

Genital/Rectal: The patient declined this examination.

Musculoskeletal: Mr. A.B. demonstrates a normal gait but slightly limps while walking due to pain in the left leg. There is tenderness to palpation over the anterior aspect of the lower leg, specifically in the area of redness and swelling. Range of motion is limited due to pain, but no deformities or joint effusions are noted.

Neurological: Mr. A.B. is alert and oriented to person, place, and time. Cranial nerves II-XII are intact. The sensation is intact in the affected leg, but he reports increased pain upon movement.

Skin: On inspection, visible erythema (redness) and edema (swelling) were noted in the lower left leg. The affected area appears warm to the touch compared to the surrounding skin. No visible signs of trauma or open wounds are observed.

Diagnostic results:

  1. Complete blood count (CBC): leukocytosis and increased neutrophils.
  2. Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
  3. Positive skin swab culture.

ASSESSMENT:

Differential diagnoses:

  1. Deep vein thrombosis (DVT),
  2. Erysipelas
  3. Contact dermatitis.

Primary Diagnoses

  1. Cellulitis

Cellulitis is the most likely diagnosis for the patient. First, the patient presents with localized redness, swelling, and warmth in the affected leg, which are characteristic signs of cellulitis (Brown & Hood Watson, 2022). The symptoms have progressively worsened over the past two days, indicating an acute infection. Additionally, the patient reports constant throbbing pain and tenderness in the affected leg, which are common symptoms of cellulitis.

Secondly, the patient has risk factors that predispose him to cellulitis. Zacay et al. (2021) highlight that his medical history reveals a diagnosis of diabetes, which increases the risk of developing skin infections. Furthermore, the patient’s paternal grandfather had cellulitis, suggesting a potential genetic predisposition. Thirdly, the physical examination findings support the diagnosis of cellulitis. The presence of erythema, edema, warmth in the lower left leg, and tenderness to palpation is consistent with cellulitis (Brown & Hood Watson, 2022). The limited range of motion due to pain also aligns with cellulitis, which can cause discomfort and hinder movement.

Finally, the diagnostic results further support the likelihood of cellulitis. The complete blood count (CBC) shows leukocytosis and increased neutrophils, indicating an inflammatory response to infection. The elevated levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are also indicative of an inflammatory process (Brown & Hood Watson, 2022). The positive skin swab culture confirms the presence of bacteria, which is commonly associated with cellulitis.

While deep vein thrombosis (DVT) is a potential differential diagnosis due to the patient’s leg pain and swelling, the absence of risk factors such as recent immobilization, surgery, or prolonged travel makes it less likely (Waheed & Hotwagner, 2021). Erysipelas is another possibility, but it typically presents with well-demarcated, raised, and intensely red lesions, which are not apparent to the patient (Michael & Shaukat, 2020). Contact dermatitis could be considered, but the absence of exposure to potential irritants or allergens makes it less probable compared to cellulitis.

References

Brown, B. D., & Hood Watson, K. L. (2022, August 8). Cellulitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549770/

Michael, Y., & Shaukat, N. M. (2020). Erysipelas. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532247/

Waheed, S. M., & Hotwagner, D. T. (2021). Deep vein thrombosis (DVT). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507708/

Zacay, G., Hershkowitz Sikron, F., & Heymann, A. D. (2021). Glycemic control and risk of cellulitis. Diabetes Care, 44(2), 367–372. https://doi.org/10.2337/dc19-1393

 

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