Diagnosis of Skin Condition Essay Assignment Paper

SUBJECTIVE DATA:

Chief Complaint (CC): The patient presents with a swollen red leg accompanied by pain

History of Present Illness (HPI): Mr. KJ is a 66-year-old Caucasian who presents to the clinic with his right leg swollen and red with severe pain. He reports the leg worsening in the past few days after being bitten by a tiny insect while in his garden. The patient says having experienced fevers and chills for the past two nights, which he has managed by taking Tylenol and Ibuprofen for pain and fever, respectively. He also states to manage the swelling by alleviating the leg throughout the day. He fears the pain may be associated with an infection because it’s becoming unbearable and making it difficult to bear his weight. He also reports having his skin feeling light, like it will rip the next minute.

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Diagnosis of Skin Condition Essay Assignment Paper

Medications:

• Tylenol 325-500 mg PRN for leg pain
• Ibuprofen 200-400m PRN for fever
• Lispro 5 units before meals
• Metoprolol 1.25mg twice a day
• Gabapentin 100mg thrice per day
• Eliquis 5mg twice per day

Allergies:

• Penicillin-rash
• Trazadone- migraines
• Sulfa- rash
• Latex- itching

Past Medical History (PMH):

• Diabetes mellitus type 2 diagnosed at 34
• Hypertension diagnosed at 30
• Neuropathy diagnosed at 34
• Deep vein thrombosis diagnosed at 30
• Hyperlipidemia diagnosed at 30 Diagnosis of Skin Condition Essay Assignment Paper

Past Surgical History (PSH): Bilateral total knee arthroplasty

Sexual/Reproductive History: The patient is a heterosexual male married to one wife. Denies any history of STDs and reproductive issues.

Personal/Social History: The patient is a retired Navy, is married, and has two children. He lives with his spouse of 30 years in their private home. He states to take short walks three or four times weekly to stay healthy. He reports having a good diet but takes more pastry as his wife is a baker. He has a degree in Economics and has engaged in trading stocks and cryptocurrency after his retirement. The patients report drinking one glass of wine after dinner. He also reports taking alcohol occasionally. He reports having smoked before but has stopped and would smoke one pack per month. He denies the use of cocaine, marijuana, or any illicit drug.

Health Maintenance:  The patient reports his last physical assessment was in 2021, which revealed elevated h1a1c levels. His last endocrinology visit was six months ago, and he was advised to stop taking Metformin and replace it with Lispro. He reports regularly monitoring his blood sugar levels at home using his glucometer but is inconsistent in keeping the records. His last eye visit was last month after experiencing blurred vision and myopia. Diagnosis of Skin Condition Essay Assignment Paper

Immunization History: The patient reports to have been up-to-date with childhood vaccinations. Reports to have received his influenza and pneumococcal vaccines sometime last year.

Significant Family History:

• Father, deceased at 87, of prostate cancer
• Mother alive, aged 92, with a history of hypertension, diabetes, and hypothyroidism
• Son, aged 30 and healthy
• Daughter, aged 33, with a record of diabetes type 2

Review of Systems:

General: The patient reports fever, chills, and pain in his leg. Denies any sweat, fatigue, weight, and appetite changes

            HEENT: Denies headache, dizziness, or seizures. Reports of blurry vision with myopia when reading. Denies any ear problems. Denies any change in smell or sinus infection. Denies any difficulties in chewing or swallowing food. Diagnosis of Skin Condition Essay Assignment Paper

            Respiratory: Denies any coughs, dyspnea, or orthopnea. Denies any breathing difficulties

            Cardiovascular/Peripheral Vascular: No chest pain, tightness, or discomfort. Denies any palpitations or murmurs.

            Gastrointestinal: Denies any stomach pains, vomiting, diarrhea, or constipation. Reports regular bowel movements.

            Genitourinary: No changes in urine color, volume, or frequency. Denies dysuria, oliguria or hematuria.

            Musculoskeletal: Limited change in motion on his right ankle associated with pain and swelling. He reports the severity of the pain to be at 8 out of 10. He is unable to bear weight on his right leg.

            Neurological: Denies dizziness, seizure, or light-headedness.

            Psychiatric: Denies history of psychiatric illness. Denies anxiety, depression, and insomnia. Denies suicidal ideations or attempts.

            Skin/hair/nails: Bruising on the upper extremities of the right leg extending from the ankle region. His right leg is swollen, and he feels the skin is tight and light. Diagnosis of Skin Condition Essay Assignment Paper

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 156/87, Weight;266 lbs, P:88 and regular, BPI:30.2, -Ht:5’8”, RR:20, T:101.6

General: He appears in pain with a sandal on his right foot and a shoe on his left leg. Reports fever, chills, and aches in his right leg.

HEENT: Head is normocephalic, conjunctiva moist and pink, sclera white and clear, EOM intact, pink and moist mucus membrane, ear canals patent.

Neck: No carotid bruits, thyroid intact, and no JVD.

Chest/Lungs. Chest expansions are symmetrical, and clear breath sounds bilaterally.

Heart/Peripheral Vascular: Regular rate and rhythm, no heart murmurs, s1,s2, and s3 audible.

Abdomen: Normoactive abdomen, no tenderness to palpations, no rigidity.

Genital/Rectal: Declined assessment.

Musculoskeletal: Muscle strength on right leg 3/5, reduced dorsiflexion with secondary pain and edema on right leg.

Neurological: Clear speech with facial symmetry intact.

Skin: Redness and edema of right leg, distal ankle mild peeling.

Diagnostic results:

ASSESSMENT:

Differential Diagnosis

• Cellulitis: This condition results from the penetration of streptococcus and staphylococcus aureus in the dermis and subcutaneous tissues. According to Sullivan & de Barra (2018), the clinical presentations of the condition include redness, swelling, burning, and severe pain in the affected area. This diagnosis is highly possible as the patient’s right leg is red and swollen with severe hot pain. Diagnosis of Skin Condition Essay Assignment Paper

• Contact Dermatitis: This skin condition results from exposure to allergens or irritants. The irritants may include detergents, foods, and cosmetics (Novak-Bilić, 2018). The primary symptoms include itching, soreness, pain, and red blisters. The patient’s red leg is red, swollen, and painful, which makes it a highly appropriate diagnosis.

• Erysipelas; The disease is caused by strains of group A streptococcus bacteria. The condition is characterized by localized lesions that are red and tender (Fetters & Villaseñor, 2021). The lesions can be hot and painful. They can be located on the hands and legs or around the infected area. This is a likely diagnosis as the patient had tender, hot, and painful redness on his right leg. Diagnosis of Skin Condition Essay Assignment Paper

Primary Diagnosis

Considering the subjective and objective patient information, cellulitis is the most appropriate diagnosis. The clinical manifestations of cellulitis include edema, redness, millimeter sized pittings, and pain,n, which correspond to the signs and symptoms presented by the patient. In addition, the patient reports the symptoms presented resulted from an insect bite which caused an open entry of bacterial penetration. This results in entering of streptococcus bacteria found on the normal skin flora, causing cellulitis. In addition, middle-aged or older adults with uncontrolled diabetes have an increased risk of cellulitis (Cranendonk et al. 2017). Mr. K.J. has a history of diabetes and is aged 66, which delayed the wound’s healing process, increasing susceptibility to infection. Diagnosis of Skin Condition Essay Assignment Paper

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References

Cranendonk, D. R., Lavrijsen, A. P. M., Prins, J. M., & Wiersinga, W. J. (2017). Cellulitis: current insights into pathophysiology and clinical management. The Netherlands Journal of Medicine, 75(9), 366–378.

Fetters, L., & Villaseñor, S. (2021). Erysipelas, the “other” cellulitis: A practical guide for nurse practitioners. The Journal for Nurse Practitioners, 17(8), 954–957. https://doi.org/10.1016/j.nurpra.2021.04.026

Novak-Bilić, G. (2018). Irritant and allergic contact dermatitis – skin lesion characteristics. Acta Clinica Croatica. https://doi.org/10.20471/acc.2018.57.04.13

Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical Medicine, 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160

Choose the Skin # 4 Cellulitis on leg

• 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 Diagnosis of Skin Condition Essay Assignment Paper

Note : i will upload the picture of the skin and you will take the number 4 ( cellulitis )
I will upload the SOAP on blank and one with data that you can use as example. Please fill the note template with data that can correspond to a patient with cellulitis and you can fill the rest with normal finding. Diagnosis of Skin Condition Essay Assignment Paper