NURS 680A Advanced Health/Physical Assessment Week 3 Discussion Forum
NURS 680A Advanced Health/Physical Assessment Week 3 Discussion Forum
Complete your weekly discussion prompt.
Select one of the following case studies to address:
A 17-year old male presents with a complaint of a red itchy rash over his torso and back x 1 week which is keeping him up at night. He denies sick exposures or recent visit to wooded areas. Denies other complaints.
A 42-year old female presents with a complaint of a papule on her left forearm for the past 2 months that “looks funny”. Denies itching, scaling, drainage, or other complaints.
A 28-year old male complains of a scaly lesion over his left groin area and a painful “cut” between his “big” and second toe x 3 weeks.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
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Sample Student Solution
S: Subjective: 17-year-old male presents with a complaint of a red itchy rash over his torso and back x 1 week which is keeping him up at night. He denies sick exposures or recent visits to wooded areas. Denies other complaints currently.
Any past medical history? Denies any past medical history (assumed)
Surgical history: Denies surgical (assumed)
When did your symptoms start?
How long do your symptoms last?
What were you doing initially before the rash started?
Do you have any shortness of breath or cough? If so, does anything exacerbate it, and is it productive?
What did your rash initially look like?
What did you eat before developing the rash?
Have you recently changed or started using any new skin products such as detergents, soaps, or lotions?
What exactly is keeping you up at night?
Any wheezing or dyspnea on exertion?
Any contributing factors?
Any recent visits to wooded areas?
Does anything make the itching better or worse?
Does your rash have any drainage, if so, what is the color of the drainage?
Have you been in contact with anyone that is ill?
Have you ever had any skin ailments such as chickenpox, shingles, scabies, or poison ivy rash?
Have you recently been out in an environment where you could have met poison ivy?
Social History? Lives at home with family, attend high school
Any friends and/or family with the same symptoms?
Do you drink alcohol, smoke/vape tobacco, or use illicit drugs?
How do you deal with stress? Coping skills? Social support?
Any recent sick contacts?
Immunizations: Not provided, the patient is presumed to be up to date on all immunizations, based on the fact he attends public school, and it is a requirement.
Allergies: Denies food, drug, medication, or environmental allergies.
Current medications: Denies taking any currently.
Height: 5’1” /Weight: 122 lbs.; BMI: 22.7(normal)- hypothetical
Vital signs: B/P 120/79 (MAP 88), Pulse: 70, oral temperature: 97.9 F., Respirations: 16, SP02: 100% on room air- hypothetical
Red itchy rash over his torso and back x 1 week
Tired from lack of sleep due to not being able to rest at night.
No other medical history.
The patient reports intense itching to the torso and back and appears tired from lack of sleep due to not being able to rest at night. He reports receiving at least 7 hours/night of sleep at baseline and states he is only receiving 4, due to intense itching. The patient is alert, oriented, and well developed for his age. He is lucid and keenly responsive, cooperative, and pleasant with questioning. He appears well-nourished, well-groomed, and dressed appropriately for the weather and his development and is age-appropriate. He is in no acute distress and denies shortness of breath, chest tightening, or tongue/throat swelling currently. No acute allergic reaction was noted.
Head, Eyes, Ears, Nose, and Throat (HEENT): Within normal limits. No noted stridor, or lymph node inflammation. Dentation appropriate. Denies throat or tongue swelling.
Constitutional assessment: reports of fatigue due to lack of sleep from itching. No reported fever, or fatigue. No noted fever, or lethargy.
Cardiac: within normal limits. No JVD. No noted murmur, gallop, or friction rub. S1 & S2 present. No noted peripheral edema. Pulses are palpable to all extremities.
Neurological: Awake, alert oriented x 4. CN I-XII is intact. Reflexes intact.
Respiratory: Clear to auscultation bilateral lung fields. No noted wheezing, rhonchi, or stridor.
GI: within normal limits. Bowel sounds are present x all 4 quadrants. Denies GI issues. Has bowel movement daily. No reported change in appetite.
GU: within normal limits. Denies hematuria, cloudy urine, dysuria, tenderness, or flank pain. Pt voids freely and is continent.
Skin: a red itchy rash over his torso and back x 1
Diagnosis: Contact dermatitis
The likelihood of developing irritant contact dermatitis (irritant contact dermatitis) increases with the substance’s duration, intensity, and concentration. Chemical or physical agents and microtrauma may produce skin irritation thus causing Irritant contact dermatitis. Physical irritants like friction, abrasions, occlusion, and detergents like sodium lauryl sulfate produce more irritant contact dermatitis in combination than alone (Litchman, et all 2022).
Differential diagnosis: Poison ivy, allergic reaction, atopic dermatitis, Impetigo, Pityriasis rosea, varicella-zoster virus. (Chickenpox), and monkeypox.
Pertinent negative: a red, itchy rash over torso, and lack of sleep due to not being able to rest at night.
Pertinent positives: He denies sick exposures or recent visits to wooded areas, otherwise healthy. NURS 680A Advanced Health/Physical Assessment Week 3 Discussion Forum
Diagnostics (labs and testing):
Patch allergen-skin test- rule out allergies that can be related to skin ailments
BUN/ Creatinine, Thyroid panel, and LFTs- to assess renal function. Uremia can cause itching. Liver or kidney disorders and thyroid abnormalities, such as hyperthyroidism, may cause itching.
Culture and skin scrapings-skin scraping samples to test for bacteria, fungus, or viruses for a definitive diagnosis
Pharmacotherapy with complementary and OTC therapy:
Topical steroids such as hydrocortisone cream help decrease inflammation. High-potency topical corticosteroids, e.g., clobetasol propionate 0.05% cream, may be used to reduce inflammation
Use of non-scented, non-irritating, and hypoallergenic soap/body wash. Avoid the use of harsh soaps that are heavily scented.
Emollients can be applied to hydrate skin.
Oral/topic anticholinergic/ antihistamine medication such as hydroxyzine, cetirizine, or Benadryl.
Use oatmeal soaks, to help soothe irritated skin.
Tacrolimus ointments and pimecrolimus creams are immunomodulating medications that can inhibit calcineurin and be helpful in allergic contact dermatitis.
Avoid irritants. Wear protective clothing when hiking or any other outdoor activities.
Follow-up within 1 week to assess the resolution of symptoms, if symptoms persist or worsen, consider a Dermatology consult/referral. “For most skin conditions, when diagnosed correctly in primary care, the General Practitioners can also prescribe and initiate the proper treatment plan, which can reduce the number of referrals to dermatologists. Overall, referrals to a dermatologist are costly. A reduction in the number of referrals could indicate a health care saving equivalent to the reimbursement of a referral (Breitbart et al., 2020).”
Litchman G, Nair PA, Atwater AR, et al. Contact Dermatitis. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459230/ (Links to an external site.)
Breitbart, E. W., Choudhury, K., Andersen, A. D., Bunde, H., Breitbart, M., Sideri, A. M., Fengler, S., & Zibert, J. R. (2020). Improved patient satisfaction and diagnostic accuracy in skin diseases with a visual clinical decision support system—a feasibility study with General Practitioners. PLOS ONE, 15(7). https://doi.org/10.1371/journal.pone.0235410 (Links to an external site.)
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