A Review of Pathogenesis Diagnosis and Management Essay
A Review of Pathogenesis Diagnosis and Management Essay
History of Present Illness (HPI): Mr. K.J, 50 year male presented with left lower limb pain and swelling for the last 5 days. He states that the symptoms began after he was pricked by a tree stump. He reports that the pain is generalized over the left leg, dull in nature, on and off, non-radiating, aggravated on movement, has no specific timing and is partially relieved by analgesics. She also states that the swelling has been increasing in size gradually and is not relieved by limb elevation or cold compressions. She has no history of contact with irritants. A Review of Pathogenesis Diagnosis and Management Essay
Medications
- PO metformin 1g 12 hourly.
- PO amlodipine 10mg 24 hourly
- PO atorvastatin 20mg 24 hourly
- PO meloxicam 15mg 12 hourly
- Apply fastum gel 12 hourly
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Allergies
He is allergic to Sulphur-based drugs.
Past Medical History (PMH)
He is a known diabetic and hypertensive patient for the last 2 years.
He states that he is compliant with his medications
Past Surgical History (PSH)
He has a positive history of hydrocelectomy 6 months ago.
Sexual/Reproductive History
He is sexually active.
Personal/Social History
He is married with three living children. He is a carpenter and owns a business.
He has a positive history of cigarette smoking and alcohol consumption during social gatherings. He denies illicit drug use. A Review of Pathogenesis Diagnosis and Management Essay
Health Maintenance
He denies taking part in physical activities.
His last physical was one year ago.
He reports that he fastens his seatbelt when travelling.
Immunization History
Vaccination schedule is up to date.
Significant Family History
He is the 4th born in a family of 6.
All siblings are alive and well.
Both parents are alive. Father is diabetic and mother is hypertensive.
Review of Systems
General: He has no history of chills, hotness of body and weight loss.
HEENT: Ear; He denies ear discharge, pain or loss of hearing. Eye: no history of visual disturbance, double vision, eye discharge and pain. Nose; No history of runny nose, denies nasal congestion, and nose bleeding. Throat: no history of painful/difficulty swallowing and sore throat. A Review of Pathogenesis Diagnosis and Management Essay
Respiratory: He has no history of cough, difficulty breathing or chest pain.
Cardiovascular/Peripheral Vascular: No history of palpitations, dyspnea and orthopnea.
Gastrointestinal: He denies having abdominal pain, difficulty and painful swallowing.
Genitourinary: He has no history increased urgency, frequency and painful urination.
Musculoskeletal: He has no history of joint pain, swelling and stiffness.
Neurological: He denies having numbness or tingling sensation of the lower limb.
Psychiatric: He has no history of feeling sad or blue. He denies having visual or auditory hallucinations.
Skin/hair/nails: He has a positive history of skin color changes on the left leg.
OBJECTIVE DATA
Physical Exam
Vital signs: Bp- 126/64mmHg, Pr- 64bpm, RBS- 7.8mmol/l, RR- 16bpm, BMI- 28kg/m2, Temp- 36.7 and Spo2- 96% in room air.
General: Mr. K.J, 50 year old American man is in a fair general condition. He is alert, oriented in time place and person. He appears to be in overall good health.
HEENT
Head: Normocephalic, no bruising, swelling or lacerations. Eyes: No redness, lesions of eyelids or eyelashes. No periorbital edema. Ears: Hearing intact bilaterally.
Nose/Mouth/Throat: Mucous membranes are pink and intact, moist no bleeding. No sputum deviation. No sores or wounds on the gum, cheek, tongue, soft or hard palette. A Review of Pathogenesis Diagnosis and Management Essay
Neck: No jugular distension, deviation of trachea or neck swelling noted.
Chest/Lungs: No chest wall deformities. Normal Rhythmic breathing. The chest is clear with no added sounds.
Heart/Peripheral Vascular: The precordium is normoactive. Normal heart sounds S1, S2.
Abdomen: The abdomen is symmetrical and moving with respiration. No masses or organomegally. Bowel sounds present.
Genital/Rectal: Patient declined
Musculoskeletal: Normal range of movement in joints of the upper and lower limb. There is normal muscle tone, power and bulk in all groups of muscles.
Neurological: Cranial nerves are intact. Short-term and long-term memory are intact.
Skin: The skin over the left lower limb is poorly demarcated and reddened. There is obvious edema that is non-tender and pitting. There is increased temperature gradient compared to the contralateral limb. A Review of Pathogenesis Diagnosis and Management Essay
Diagnostic Results
- HBA1C: To check glucose control over the last three months
- Complete blood count: Check for evidence of leukocytosis.
- c-reactive protein: Inflammatory marker that checks for evidence of an infection.
- D-dimer: To check the clotting factors for rule out DVT.
- Doppler Ultrasound: Check for thrombus formation in the deep venous system of the lower limb.
ASSESSMENT
Cellulitis (LO3.116): A bacterial skin infection that causes inflammation of the subcutaneous tissue and the deep dermis that often results from a break in the skin (Rrapi et al., 2021). The diagnosis is probable since Mr.K.J is diabetic and had a history of skin injury. The patient also presented with symptoms such as pain, swelling, erythema and warmth which is the typical presentation.
Deep Vein Thrombosis (I82.402): A blood clot that forms within the deep venous system mostly of the legs. Risk factors include venous stasis, endothelial damage and hypercoagulable state (Kruger et al., 2019). The clinical presentation includes swelling, pain and redness. Mr.K.J needs further investigations to rule out the diagnosis. A Review of Pathogenesis Diagnosis and Management Essay
Necrotizing Fasciitis (M72.6): A flesh eating bacteria that leads to necrosis of the subcutaneous tissue and muscle fascia. The clinical presentation includes pain, systemic septic signs, ecchymotic skin colour changes, presence of bullae and others (Chen et al., 2020). Mr.K.J did not present with the above symptoms therefore rendering the diagnosis less probable.
Contact dermatitis (L30.9): An inflammatory disease that results from metal ions or chemicals that elicit toxic effects (Sedó-Mejía et al., 2020). Patients present with symptoms such as itching, burning, pain and soreness. Mr.K.J does not report of any contact with irritants or allergies thus ruling out the diagnosis.
Diabetic foot ulcer (E11.621): A complication of poorly controlled blood glucose levels. According to Akkus & Sert, (2022), it results from factors such as peripheral vascular disease, neuropathy, poor glycaemic control, neuropathy and poor foot care. Since Mr.K.J is diabetic, he is at an increased risk, however, the blood glucose levels are well control and also did not present with symptoms such as neuropathy therefore the diagnosis is not likely.
References
Akkus, G., & Sert, M. (2022). Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities. World Journal of Diabetes, 13(12), 1106–1121. A Review of Pathogenesis Diagnosis and Management Essay https://doi.org/10.4239/wjd.v13.i12.1106
Chen, L. L., Fasolka, B., & Treacy, C. (2020). Necrotizing fasciitis. Nursing, 50(9), 34–40. https://doi.org/10.1097/01.NURSE.0000694752.85118.62
Kruger, P. C., Eikelboom, J. W., Douketis, J. D., & Hankey, G. J. (2019). Deep vein thrombosis: update on diagnosis and management. Medical Journal of Australia, 210(11), 516–524. https://doi.org/10.5694/mja2.50201
Rrapi, R., Chand, S., & Kroshinsky, D. (2021). Cellulitis: A Review of Pathogenesis, Diagnosis, and Management. The Medical Clinics of North America, 105(4), 723–735. https://doi.org/10.1016/j.mcna.2021.04.009
Sedó-Mejía, G., Soto-Rodríguez, A., Pino-García, C., Sanabria-Castro, A., & Monge-Ortega, O. P. (2020). Contact dermatitis: Clinical practice findings from a single tertiary referral hospital, a 4-Year retrospective study. World Allergy Organization Journal, 13(7), 100440. https://doi.org/10.1016/j.waojou.2020.100440
NURS_6512_Week_4_Assignment_1_Rubric
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| NURS_6512_Week_4_Assignment_1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic. |
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35 pts | ||||
| Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature. |
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50 pts | ||||
| Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
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5 pts | ||||
| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
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5 pts | ||||
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
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5 pts | ||||
| Total Points: 100 | ||||||
Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment. A Review of Pathogenesis Diagnosis and Management Essay
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. A Review of Pathogenesis Diagnosis and Management Essay
