Nursing Lab Assignment: Differential Diagnosis for Skin Conditions

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Lab Assignment: Differential Diagnosis for Skin Conditions

Student’s Name

Institutional Affiliation

Course

Date

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Lab Assignment: Differential Diagnosis for Skin Conditions

Purpose: This paper aims to perform a differential diagnosis of a skin condition depicted in

graphic no. 4. Through objective assessment, the paper records observations and analyses them

to come up with a differential diagnosis as per the SOAP format.

Week 4: Skin Comprehensive SOAP Note

Patient Initials: __H.K___Age: __45_____Gender __M____

Subjective Data

Chief Complaint (CC): Redness, pain, and swelling of the skin on the left leg, fever.

History of Present Illness (HPI): H.K. is a 45-year-old Caucasian male who reports fever and

severe soreness, swelling, and redness of the skin on the left leg. The patient also complains of

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fever before the discovery of erythema on the leg, which spread over a larger skin area with time.

The patient also reported hitting his leg on a hard surface during his regular plumbing work

schedule. The accident did not lead to an open wound immediately, and there was no bruising or

broken skin. Also, he did not take any medications for the fever but applied first aid by placing

ice on the hit area once the pain progressed. The patient denied any use of painkillers or

application of any form of cream.

Medications:

i. Inderal 120 mg extended release, orally, daily

ii. Losartan 100 mg, orally, daily

iii. Bumex 3 mg, twice a day

iv. Protonix 20 mg, orally, daily

v. Coreg 25 mg, orally, twice a day

vi. Hydralazine 100 mg, thrice a day

vii. Lantus 12 units taken subcutaneously

viii. Citalopram 40 mg, orally, every day

vi. Insulin a part, administered bedtime subcutaneously after every meal

vii. Lipitor 80 mg, orally, every day

Allergies:

The patient reports an allergic response to Tetracycline Adhesive.

Past Medical History:

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i. Hypertension

ii. Depression

iii. Morbid obesity Diabetes Mellitus

iv. Gastro-esophageal reflux disease (GERD)

v. Hyperlipidemia

Past Surgical History (PSH):

i. Right shoulder arthroscopy

ii. Laser eye surgery in 2018

Sexual/Reproductive History: heterosexual, sexually active.

Personal/Social History: The patient reports smoking cigarettes about five years ago but

managed to quit. He takes alcohol-based drinks with a friend, especially on weekends. He denied

the use of any narcotic drugs throughout his life. His hobbies include playing chess, and

draughts, riding m motorcycle, participating in humanitarian aid and charitable events, and going

for morning runs.

Health Maintenance:

The patient reported exercising on a daily bases through morning runs and avoiding starch and

sugary foods due to the morbid obesity and diabetes history.

Immunization History: The patient reported receiving all pre-requisite immunizations,

including Covid-19 vaccinations and booster shots.

Significant Family History: The maternal grandfather has a history of hyperlipidemia, while the

father has hypertension. The patient is a singleton with both parents.

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Review of Systems:

General: The patient reported frequent fever, soreness, redness, swelling, and pain of the

erythema on the left leg.

HEENT: The patient did not report any blurry vision. He wears spectacles due to short-

sightedness. The patient denied any ear discharge or pain and any running nose in the last month.

Respiratory: The patient denied any shortness of breath, coughing, or congestion. The patient

denied any chest pain but has a history of smoking. The patient did not report any withdrawal

symptoms from smoking. The patient has a history of pneumonia but denied tuberculosis.

Cardiovascular/Peripheral Vascular: The patient has a history of hypertension and

hyperlipidemia. He denied any chest pain or palpitations but reported soreness, redness, swelling,

and pain in the lower left limb.

Gastrointestinal: The patient denied any abdominal discomfort or pain.

Genitourinary: There were no medical records of dysuria, hematuria, or any other kidney

disease.

Musculoskeletal: The patient reported pain in the lower part of the left leg. He did not report

any joint, arm, or leg weakness. He also denied joint swelling and arthritis.

Neurological: The patient denied any focal motor anomalies, stroke, paresthesia, or seizures.

Psychiatric: The patient reported depression and anxiety but denied phobias, nightmares,

nervousness, hallucinations, delusions, and suicidal or homicidal ideation.

Skin/hair/nails: The patient reported swelling, soreness, redness, pain in the skin of the left

lower leg, and erythema.

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Objective Data

Physical Exam:

Vital signs:

Body Temp: 38

Weight: 112kg (247 lbs)

Height: 6' 3.7"

Pulse rate: 68

RR: 18 (non-labored)

CBP: 152/83

BMI: 31.4 kg/m²

General: A well-dressed man with a normal temperate, kind, face comforted and sensitive to

anyone trying to touch the leg.

HEENT: The extraocular muscles were intact (EOMI), the patient had normal eyelids, pupils

that were equal, round, and reactive to light (PERRL) normal lids, pupils are equal, round and

react to light, normocephalic, pink conjunctiva, normal distribution of hair, and a clear sclera.

The patient denied any soreness, discomfort, or pain of the year.

Neck: an assessment of the trachea revealed no signs of lymphadenopathy or chiromegaly. The

trachea had a moist mucous membrane.

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Chest/Lungs: The patient did not report any wheezing, rubs, or crackling, and both lungs were

free of auscultation. The patient also presented normal fremitus, symmetric chest expansion, and

resonance on percussion.

Heart/Peripheral Vascular: The patient has a normal heart rate and rhythm and has no signs of

cyanosis or pallor. Also, the patient has a normal S1 and S2. The patient has +2 left leg edema,

+2 capillary refill in the lower extremity, and +1 right leg edema. The patient also has no S3 or

S4.

Abdomen: The patient reports abnormal bowel sounds and denied any abdominal sounds. The

were no signs of bruits or organomegaly.

Genital/Rectal: The patient is circumcised and did not have any penile lesions, testicular lumps,

or penile discharge. The rectal examination revealed no lesions, masses, or tenderness.

Musculoskeletal: There were no signs of Scoliosis and kyphosis, and the patient denied any

joint swelling or stiffness.

Neurological: The patient had normal speech and a normal sensation that was oriented to person,

time, and place.

Skin: There were signs of more left lower extremity edema in comparison with the right lower

extremity. The were no signs of skin, open wound, or discharge. There was erythema in the left

lower limb along the mid-shin and its anterior region. However, there were no ulcerations. There

was also a slight abrasion on the left shin. A bilaterally palpable arterial pulse revealed a warmer

and tender lower left extremity in comparison to the lower right extremity.

Diagnostic/Lab Tests and Results:

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1. CBC test revealed leukocytosis with >13000 leukocytes/µL

2. Skin biopsy

3. CRP test revealed higher than normal results at 115 mg/L

ASSESSMENT

Differential Diagnosis 1: Cellulitis.

Cellulitis, commonly referred to as streptococci, is a skin infection that affects

subcutaneous skin layers and causes severe pain in the affected areas (Patel et al., 2018). The

skin condition is caused by an unknown streptococcus. The condition occurs when pathogens

enter the subcutaneous layers through broken skin. The condition is also difficult to diagnose and

distinguish from other skin conditions, which manifest in very similar ways. The disease

manifests in a subcutaneous region with an inferior boundary, mostly in the lower extremities.

However, the disease can also occur in the upper extremities if a patient is administered

an intravenous drug. The disease is accompanied by inflammatory signs, consisting of fever,

swelling, tenderness, and pain in the infected area. From graphic 4, the patient has red and

slightly swollen skin on the lower extremity, with visible sores. The accident that led to hitting

the leg on a surface may have caused the streptococcus to penetrate the skin and cause Cellulitis.

Differential Diagnosis 2: Erysipelas

Erysipelas is a skin infection of the dermis, which mainly manifests in the lower limbs or

face. The disease's symptoms include skin tenderness, a well-delineated and raised erythema,

fever, and malaise. The disease is caused by Streptococcus Pyogenes, a bacterium that is also

referred to as hemolytic streptococci (Brindle et al., 2020). The bacteria enter the skin through a

scratch of the skin or through an insect bite. The disease has very similar signs and symptoms to

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Cellulitis, but it is usually more demarcated and raised. Signs of the symptoms include a red

plaque, a raised edge, swollenness, tenderness, and warmth of the skin on the affected area.

Differential diagnosis 3: Necrotizing

The disease is a severe skin infection affecting the subcutaneous later and skin facia and

is prevalent in the lower skin areas (Puntis, 2018). The disease spreads fast and often calls for

emergency surgery. Its symptoms include fever, swelling, tenderness, and pain in the infected

area, which are very close to those of Cellulitis. The symptoms keep on changing with time,

unlike Cellulitis, whose symptoms are very specific. In the later stages, the disease manifests in

the form of gas gangrene and necrosis. From graphic number four, the patient has tenderness of

the skin, red ores, and swelling, but lacks any signs of gas gangrenes, thus disqualifying the

Necrotizing diagnosis.

Differential Diagnosis 4: Erythema nodosum

Erythema nodosum is a skin infection commonly located at the lower extremities and

manifests in the form of erythematous and nodular eruption (Gilchrist & Patterson, 2010). The

disease is considered a reaction caused by hypersensitivity to immune depositions by vessels

located in the panniculus adiposis. It is also comorbid with other systemic diseases and certain

therapeutic interventions.

Differential diagnosis 5: Contact Dermatitis

The disease is an itchy rash caused by contact with a substance that causes an allergic

reaction to the skin. Such substances include plants, cosmetics, jewelry, and fragrances. Signs

and symptoms include swelling, warmth, or tenderness of the skin on the affected region, an

itchy rash, blisters, and leathery patches (Marty & Cheng, 2005).

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Primary Diagnoses: While many skin diseases manifest with similar symptoms, there are

distinguishing features that set apart a specific disease. Considering that the person hit his leg

on a blunt object which did not cause broken skin, but the disease emerged after the accident,

it is most likely that bacteria entered the skin during the impact, thus implying a high

likelihood of Cellulitis. Also, the disease affected the subcutaneous tissue, which rules out

erysipelas. Also, there were no reports of deep-seated nodules, and the signs and symptoms

were consistent with Cellulitis. Therefore, the primary diagnosis is Cellulitis.

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References

Brindle, R. J., O'Neill, L. A., & Williams, O. M. (2020). Risk, prevention, diagnosis, and

management of Cellulitis and erysipelas. Current Dermatology Reports, 9(1), 73–82.

https://doi.org/10.1007/s13671-020-00287-1

Gilchrist, H., & Patterson, J. W. (2010). Erythema nodosum and erythema induratum

(nodular vasculitis): Diagnosis and management. Dermatologic Therapy, 23(4), 320-

327. https://doi.org/10.1111/j.1529-8019.2010.01332.x

Marty, C. L., & Cheng, J. F. (2005). Irritant contact dermatitis precipitating allergic contact

dermatitis. Dermatitis (formerly American Journal of Contact Dermatitis), 16(02),

087. https://doi.org/10.2310/6620.2005.04028

Patel, M., Lee, S., Thomas, K., & Kai, J. (2018). The red leg dilemma: A scoping review of

the challenges of diagnosing lower‐limb Cellulitis. British Journal of Dermatology,

180(5), 993-1000. https://doi.org/10.1111/bjd.17415

Puntis, J. (2018). Necrotizing enterocolitis. Oxford Medicine Online.

https://doi.org/10.1093/med/9780198759928.003.0007