case study

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Week2discussion.pdf

Dermatologic Differential of Common Skin Lesions and Rashes

Name Cause Sign/symptoms Diagnostics Treatment Concerns Rocky Mountain Spotted Fever

Tick bite Rickettsia rickettsii

Fever, chills, severe headache, n/v, photophobia, myalgia, conjunctival injection, arthralgia; 2-5 days after onset - rash (petechiae) starts on hands/feet to trunk (palmar rash)

Antibody titers to rickettsia Punch biopsy CBC, LFT, CSF

Doxycycline 100mg BID for 7-14 days – can be fatal if not started on treatment within 8 days. Remove tick by grasping closest to skin and apply steady upward pressure

Can be fatal (3- 9%) Highest in southeast ern/sout h central regions of US Most common Apr - Sept

Erythema Migrans (Lyme disease) Meningococ cemia

Varicella / Zoster

Malignant Melanoma

Basal Cell Carcinoma

Actinic Keratosis

Erythema Multiforme (Stevens- Johnson syndrome)

Differential Diagnoses of Eye Emergencies

Name Cause Signs/Sym ptoms

Diagnostics Treatments Concerns

Corneal Abrasion

Trauma, foreign body, incorrect use of contact lenses

Acute onset severe eye pain with tearing. Reports feeling of foreign body sensation

Eye exam with Fluorescein dye

Flush eye with sterile normal saline. Evert eyelid to look for foreign body. Topical antibiotic trimethoprim- polymyxin B (Polytrim),Ciproflox acin (Ciloxan), Ofloxacin (Ocuflox) to affected eye 3-5 days. Do not patch eye.

Contact Lens- Related Keratitis – acute onset red eye, blurred vision, watery eyes, photoph obia, foreign body sensation

Hordeolum (Stye)

Chalazion Pinguecula Pterygium Subconjunctiv al Hemorrhage

Primary Open-Angle Glaucoma

Macular Degeneration

Differential Diagnoses of Common Headaches

Name Sign/symptom s

Aggravating factors

Acute treatment

Prophylaxis

Migraine Without Aura

Throbbing pain behind one eye, photophobia, N/V phonophobia, last 4-72 hr.

Red wine, MSG, aspartame, menstruation, stress

Ice pack on forehead, rest in dark quiet room Triptans, Tigan suppositorie

TCAs Episodic migraine (<14 days per month) Beta-blockers

Migraine With Aura

Trigeminal Neuralgia (CN V)

Cluster Muscle Tension

Part 2: Case Study

A 48-year-old male presents with a two-month history of nighttime headaches that are becoming more frequent. The pain awakens him at night. He has no other somatic complaints and no other significant medical history. Complete chart below.

In SOAP format, discuss what questions you would ask the patient (Review of Systems), what physical exam elements you would include, what further testing you would want to have performed (if any), differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.

Differential Signs/Symptoms Gold Standard Diagnostics

Gold Standard Treatment

Ex: Temporal arteritis (giant cell arteritis/GC A)

Unilateral pain, temporal area with scalp tenderness, skin over artery is indurated, tender, warm and reddened; amaurosis fugax (temporary blindness).

Medical urgency – refer to ED or Ophthalmolog ist

High dose steroids * Dose and route of administration of glucocorticoids for newly diagnosed GCA varies depending on whether patient presents with or without threatened or established visual loss at diagnosis.

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