Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
Assignment 1: Differential Diagnosis of Skin Disorders
Patient Initials: J.D. Age: 20years Gender: M
Chief Complaint (CC): “I have painful blisters on the skin that are very itchy.”
History of Present Illness (HPI): J.D is a 20-year-old Caucasian patient who presented to the clinic with symptoms of painful blisters on the skin that cause pruritus. He states that the blisters appeared five days ago. The blisters are located on one side of the back. The symptoms started seven days ago when he experienced an abnormal skin sensation with mild pain on the affected part. The symptoms were accompanied by malaise and mild headaches. Two days later, he noticed some red spots which quickly progressed into painful blisters that occurred in a cluster. He describes the pain as burning, severe and constant, which causes a lot of itching. The patient further mentions that some of the blisters ruptured, forming ulcers that develop into crusts. He states that pain has no triggering or relieving factors. The patient has tried using Hydrocortisone cream to relieve the itching, but it had no significant impact. He rates the pain as 7/10.
Medications: OTC Hydrocortisone cream, B.D.
Past Medical History (PMH): No history of chronic illnesses. History of chickenpox when he was 8-years-old, treated with Topical calamine.
Past Surgical History (PSH): Appendectomy due to appendicitis in Nov 2013.
Sexual/Reproductive History: Has one sexual partner. Reports using condoms for protection.
Personal/Social History: J.D is a 2nd-year college student studying Business management in a community college. He lives with his parents and two siblings in Atlanta, GA. He takes alcohol, whiskey, on leisure time about two glasses. Denies tobacco or illicit drug use. Interests include playing basketball and is the captain of the school’s basketball team. Denies experiencing any difficulties in performing ADLs. Takes at least three meals a day with snacks between meals. Takes at least six glasses of fluids, including fruit juices, milk, and water.
Immunization History: Immunization up-to-date. The last influenza shot was nine months ago.
Significant Family History: The paternal grandmother died from stroke at 83 years. Both parents are alive and well. The younger brother, 8-years-old, has Asthma.
Lifestyle: Denies engaging in any cultural practices harmful to his health. Economically supported by the mother and father. Has a part-time job as a bookshop attendant. He reports having friends from college and at home.
Review of Systems:
General: Fever and loss of appetite
HEENT: Reports headache. Denies visual disturbances, ear discharge, hearing loss, nasal discharge, or swallowing difficulties.
Neck: Denies neck stiffness or pain.
Breasts: Denies breast pain.
Respiratory: Denies cough, sputum production, or shortness of breath
Cardiovascular/Peripheral Vascular: Denies SOB on exertion, chest pain, or palpitations.
Gastrointestinal: Denies nausea/vomiting, epigastric pain, abdominal pain, or changes in bowel movements.
Genitourinary: Denies urinary urgency or frequency, dysuria, bloody urine, or penile discharge
Musculoskeletal: Denies muscle pain, joint pain, or joint stiffness.
Psychiatric: Denies history of depression or anxiety disorders.
Neurological: Denies history of seizures, dizziness, syncope, burning sensations, or gait/posture difficulties.
Skin: Painful blisters with itching (Refer to HPI)
Hematologic: No history of blood transfusion.
Endocrine: Denies acute thirst, excessive hunger, or cold/heat intolerance.
Allergic/Immunologic: NKDFA. No hx of Allergic conditions.
Vital signs: Ht. – 5’4, Wt. – 132 pounds RR- 16, HR-82, BP-112/76, and Temp- 99.14F
General: Male teenage patient in no acute distress. Has normal gait and posture. Neat and appropriately dressed for the weather. Alert, oriented X3, and maintains eye contact.
HEENT: Head- normocephalic and atraumatic. Sclera white and conjunctiva pink. PERRLA. T.M.s intact. Nasal septum is intact. Mucous membranes intact, pink and moist. The tongue pink and midline. Tonsillar glands are non-inflamed.
Neck: Symmetrical; thyroid gland normal.
Chest/Lungs: Unison chest rise and fall. Lungs clear on auscultation.
Heart/Peripheral Vascular: No edema or distension of neck veins. RRR, S1 and S2 present. S gallop, heart murmurs, and friction rubs absent.
Abdomen: B.S. present in all quadrants. No abdominal tenderness or organomegaly
Genital/Rectal: Normal male genitalia. No rectal fissures or masses.
Musculoskeletal: Normal gait and posture. Full ROM; muscle strength 5/5
Neurological: C.N.s intact.
Skin: Dermatomal clusters of swollen red vesicles on the superficial layer of the left lower back. Vesicles elevated about 0.5 cm and filled with purulent fluid. Lesions appear in a linear pattern. Crusts present on parts of the dermatome (Image 5).
Herpes Zoster: Herpes Zoster, also known as shingles, is a viral condition caused by reactivation of the varicella-zoster virus. The virus remains dormant in the sensory ganglia of the cranial nerve or the dorsal root ganglia after a varicella infection (Johnson et al., 2015). Herpes Zoster typically presents with a prodromal phase of fever, malaise, and excruciating burning pain. The pain is caused by the outbreak of vesicles that occur in one to three crops over three to five days (Johnson et al., 2015). The lesions are distributed unilaterally within a single dermatome.
Herpes zoster occurs in three phases of infection, pre-eruptive, acute eruptive, and chronic phase. The Pre-eruptive stage is characterized by abnormal skin sensations or pain within the dermatome affected (Nair & Patel, 2019). An individual may experience headaches, general malaise, and photophobia. The acute eruptive phase is characterized by the vesicles and the symptoms in the pre-eruptive phase (Nair & Patel, 2019). The lesions start as macules and quickly transform into painful vesicles. The vesicles often rupture, ulcerate and ultimately crust over (Ball et al., 2019). The chronic phase is characterized by recurrent pain that lasts more than four weeks (Nair & Patel, 2019). The patient also experiences paresthesia, shock-like sensations, and dysesthesia.
Herpes zoster is the priority diagnosis based on the patient’s positive history of Varicella infection, abnormal skin sensation with pain and symptoms of headache, fever, and malaise (Ball et al., 2019). Besides, the patient’s skin symptoms started as macules that progressed into fluid-filled vesicles. Other positive findings include erythematous fluid-filled vesicles occurring in clusters unilaterally on the lower back and presence of crusts.
Dermatologic Herpes simplex: Herpes simplex is characterized by tenderness, pain, paresthesia, or mild burning at the infected site. This occurs before the onset of the lesions. On physical exam, clustered vesicles appear on an erythematous base, which then erodes, forming a crust (Ball et al., 2019). The vesicles can occur on any part of the body (Ball et al., 2019). It presents with vesicles similar to Herpes zoster, but the lesions are less painful, and they do not extend over an entire dermatome. Herpes simplex is a differential diagnosis based on pertinent positive findings of clustered erythematous vesicles and pain on the affected skin region.
Dermatitis Herpetiformis: Dermatitis herpetiformis present with erythematous clustered papules and vesicles that progress to form excoriations and urticarial plaques (Clarindo et al., 2014). Herpetiformis lesions usually develop on the extensor surfaces of elbows, buttocks, knees, and the trunk. The lesions are extremely pruritic, and the vesicles excoriate, resulting in erosions (Clarindo et al., 2014). Pertinent positive findings of Dermatitis herpetiformis include erythematous vesicles in a clustered pattern with pruritus and crusts.
Impetigo: Impetigo presents with lesions itch and burn. Lesions occur mainly on the face but can also occur in other body parts (Pereira, 2014). Impetigo is characterized by small erythematous macules that develop into a vesicle or bulla with a thin roof. The lesions occur in clusters. The vesicles rupture resulting in honey-colored clusters (Pereira, 2014). Impetigo is a differential diagnosis based on the presence of erythematous fluid-filled vesicles occurring in clusters.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th Ed.). St. Louis, MO: Elsevier Mosby.
Clarindo, M. V., Possebon, A. T., Soligo, E. M., Uyeda, H., Ruaro, R. T., & Empinotti, J. C. (2014). Dermatitis herpetiformis: pathophysiology, clinical presentation, diagnosis and treatment. Anais Brasileiros de dermatologia, 89(6), 865–877. https://doi.org/10.1590/abd1806-4841.20142966
Johnson, R. W., Alvarez-Pasquin, M. J., Bijl, M., Franco, E., Gaillat, J., Clara, J. G., Labetoulle, M., Michel, J. P., Naldi, L., Sanmarti, L. S., & Weinke, T. (2015). Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective. Therapeutic advances in vaccines, 3(4), 109–120. https://doi.org/10.1177/2051013615599151
Nair, P. A., & Patel, B. C. (2019). Herpes Zoster (Shingles). In StatPearls [Internet]. StatPearls Publishing.
Pereira L. B. (2014). Impetigo – review. Anais brasileiros de dermatologia, 89(2), 293–299. https://doi.org/10.1590/abd1806-4841.20142283