NURS 6512 Differential Diagnosis for Skin Conditions 

Sample Answer for NURS 6512 Differential Diagnosis for Skin Conditions Included After Question

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 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. 

A Sample Answer For the Assignment: NURS 6512 Differential Diagnosis for Skin Conditions 

Title: NURS 6512 Differential Diagnosis for Skin Conditions 

Skin Comprehensive SOAP Note

This SOAP NOTE will focus on image #1.

Patient Initials: AD     Age: 34                       Gender: Male

SUBJECTIVE DATA:

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. 

Medications: None

Allergies:  No known drug or food allergies.

Past Medical History (PMH):

  1. Tonsilitis
  2. Appendicitis

Past Surgical History (PSH):

  1. Tonsillectomy
  2. Appendectomy

Sexual/Reproductive History:

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.

Personal/Social History:

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.

Health Maintenance:

AD presents annually for a routine physical exam. He reports bloodwork 2 years ago at an annual exam.

Immunization History:

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.  

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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.

NURS 6512 Differential Diagnosis for Skin Conditions 
NURS 6512 Differential Diagnosis for Skin Conditions 

            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.

OBJECTIVE DATA:

 Physical Exam:

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.

ASSESSMENT:

Differential Diagnosis

  1. 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.
  2. 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.
  3. 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.
  4. 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.

Primary Diagnosis

  1. Median nail dystrophy

References

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. https://www.ejmcm.com/article_4114_44f01b00119c36ca34c67eea5116ed45.pdf

A Sample Answer For the Assignment: NURS 6512 Differential Diagnosis for Skin Conditions 

Title: NURS 6512 Differential Diagnosis for Skin Conditions 

SUBJECTIVE DATA:

Chief Complaint (CC): “I have some stretch marks and a line on my abdomen’

History of Present Illness (HPI): A.T. is a 28-year-old female client that came to the clinic with complaints of abnormal stretch marks and a line on her abdomen. The client is pregnant. The gestation of her pregnancy is 28 weeks. She has never started her antenatal clinic visits. The patient reports that the problem started four weeks ago and she was hopeful that it would diminish over time. She denied any associated symptoms such as pain or itchiness. However, she was worried that she may be having a skin condition that would require immediate intervention. She has not used any skin medications for the problem.

Medications: The patient denied any current use of medications. She reported occasional use of Tylenol 1 gram for headaches.

Allergies: The patient reported allergic reaction to Penicillin and pollen. She denied food allergies.

Past Medical History (PMH): The patient reported a history of hospitalization when she was 18 years old because of pneumonia. She denied any history of chronic conditions such as diabetes and depression. She also denied any history of blood transfusion.

Past Surgical History (PSH): The patient denied any history of surgeries

Sexual/Reproductive History: The patient is sexually active. Her last menstrual period was 21/10/2022. She denied any history of sexually transmitted infections. She also denied any history of increased urgency, frequency, and dysuria. She does not have any history of pregnancy loss or use of contraceptives. She is heterosexual.

Personal/Social History: The patient is married. She is the first born in a family of three. Her parents are both alive. This is her first pregnancy. She works as an accountant in a local firm. She does not use alcohol or smokes. She engages in moderate physical activities twice weekly. She is a Christian. She considers her family her source of social support. She denies stress.

Health Maintenance: The patient engages in moderate exercises twice weekly. She does not take alcohol or smokes. She reports that she takes healthy diet. Her immunization record is up-to-date. She has not started her antenatal clinic despite her pregnancy being 28 weeks. She denies caffeine use. She has not undergone cervical cancer screening. She performs monthly self-breast examination. Her last dental and eye examinations were two years ago and were unremarkable.

Immunization History: Her immunization record is up-to-date.

Significant Family History: The client reports that her parents are both hypertensive. Her mother is diabetic. Her paternal grandmother and grandfather died of coronary artery disease. Her maternal grandmother died of cervical cancer. Her sister is obese. Her brother was recently diagnosed with substance use disorder.

General: The patient is well dressed for the occasion. She denied fatigue, fever, chills or night sweats. Reports weight gain of 10 pounds since she became pregnant.

HEENT: She denies changes in vision or hearing; she does wear glasses. She has no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She has had no recent ear infections, tinnitus, or discharge from the ears. She denied changes in sense of smell. She does not have a history of nasal polyps or recent sinus infection. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

Neck: She denies pain, injury, or history of disc disease or compression..

Breasts: She denies history of lesions, masses or rashes.

Respiratory: She denies cough, hemoptysis, difficulty breathing or chest pain. She a history of community acquired pneumonia when she was 18 years.

CV: She denies chest discomfort, palpitations, history of murmur. She has no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication.

GI: She denies nausea or vomiting, abdominal pain. She also denies changes in bowel/bladder pattern.

GU: She denies change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She denies history of STD’s or HPV. She is sexually active.

MS: She denies arthralgia/myalgia, arthritis, gout or limitation in her range of motion.

Psych: She denies history of anxiety or depression. She also denies sleep disturbance, delusions or mental health history.

Neuro: She denies syncope episodes or dizziness, paresthesia, change in memory or thinking patterns. She also denies twitches or abnormal movements, gait disturbance, falls or seizure history.

Integument/Heme/Lymph: She reports stretch marks and a line in the middle of her abdomen. She denies rashes, itching, or bruising.

Endocrine: She denies polyuria/polyphagia/polydipsia. She also denies fatigue, heat or cold intolerances, or shedding of hair

Allergic/Immunologic: She is allergic to Penicillin and pollen. She has no food allergies.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 124/78, left arm, sitting, regular cuff; P 82 and regular; T 99.9 Orally; RR 20; non-labored; Wt: 168 lbs; Ht: 6’5

General: A&O x3, NAD

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jugular venous distention or thyromegally

Chest/Lungs: Lungs clear of wheezing or rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD:  presence of bilateral strae gravidarum and central linea nigra. Normal bowel sounds with no organomegaly and suprapubic

Genital/Rectal: Non-contributory

Musculoskeletal: symmetric muscle development. Muscle strengths 5/5 all groups.

Neuro: Normal cranial nerve assessment with no gait imbalance or coordination problems. There is no loss of sensitivity to touch.  

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

Diagnostic results: Obstetrics ultrasound performed one day ago: Intrauterine live pregnancy at 28/40 weeks in breech presentation. FHR-132 bpm, BPP 8/8, cervix closed

ASSESSMENT:

Differential Diagnosis

  1. Linea nigra: Linea nigra is a hyperpigmentation characterized by a vertical line running down the middle of the abdomen. It is an indicator of pregnancy.
  2. Strae gravidarum: Strae gravidarum refers to atropic linear scars that pregnant mothers develop. The form as stretch marks on the abdomen and diminish over time.
  3. Post-inflammatory hyperpigmentation: Post-inflammatory hyperpigmentation is a disorder that develops after skin injury or inflammation. It is severe in dark-skinned individuals. It improves spontaneously but can also require treatment for immediate changes (Lawrence & Al Aboud, 2023). It is the least likely condition since the patient in the case study is pregnant.
  4. Melanocytic naevi: Melanocytic nevi are benign hematomas or neoplasms that cause skin hyperpigmentation. It mainly affects the central nervous system and the skin. Melanocytic nevi are the least likely cause of the client’s problem since they do not occur in features such as midline vertical line that is seen in pregnancy (Yeh, 2023)

Primary diagnosis

  1. Normal pregnancy with features that include linea nigra and strae gravidarum: The client’s primary diagnosis is normal pregnancy with features that include linea nigra and strae gravidarum. Linea nigra is a normal occurrence in pregnant women. It refers to a form of hyperpigmentation that is witnessed in pregnancy. It is a dark vertical line running down the middle of the abdomen. It is an indicator of pregnancy. Linea nigra is associated with nipple, genital areas, and areola hyperpigmentation (Cappanera, 2022; Ferrando et al., 2019; Sharma et al., 2019). Strae gravidarum refers to atrophic linear scars that develop on the abdomen during pregnancy. They appear as stretch marks that may be of considerable concern to pregnant women (Dai et al., 2021). Strae gravidarum is non-pathological. The stretch marks fade over time and become hypopigmented (Karhade et al., 2021). The patient in the case study has these features, hence, a diagnosis of linea nigra and strae gravidarum. The patient is also pregnant, hence, the primary diagnosis with these conditions.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

References

Cappanera, F. F., Gisella Sorrentino, Elena. (2022). Linea Nigra: Post/Human M/Others. In Engaging Donna Haraway. Routledge.

Dai, H., Liu, Y., Zhu, Y., Yu, Y., & Meng, L. (2021). Study on the methodology of striae gravidarum severity evaluation. BioMedical Engineering OnLine, 20(1), 109. https://doi.org/10.1186/s12938-021-00945-w

Ferrando, B. F., Sorrentino, G., & Cappanera, E. (2019). Linea Nigra: Post|Human M|Others. A/b: Auto/Biography Studies, 34(3), 501–505. https://doi.org/10.1080/08989575.2019.1664152

Karhade, K., Lawlor, M., Chubb, H., Johnson, T. R. B., Voorhees, J. J., & Wang, F. (2021). Negative perceptions and emotional impact of striae gravidarum among pregnant women. International Journal of Women’s Dermatology, 7(5, Part B), 685–691. https://doi.org/10.1016/j.ijwd.2021.10.015

Lawrence, E., & Al Aboud, K. M. (2023). Postinflammatory Hyperpigmentation. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559150/

Sharma, A., Jharaik, H., Sharma, R., Chauhan, S., & Wadhwa, D. (2019). Clinical study of pregnancy associated cutaneous changes. International Journal of Clinical Obstetrics and Gynaecology, 3(4), 71–75. https://doi.org/10.33545/gynae.2019.v3.i4b.292

Yeh, I. (2023). Melanocytic naevi, melanocytomas and emerging concepts. Pathology, 55(2), 178–186. https://doi.org/10.1016/j.pathol.2022.12.341