QUESTION.

Description

PART 1: COMPLETE THE FOLLOWING DIFFERENTIAL DIAGNOSES TABLES.

All students must complete the following differential diagnoses tables. An exemplary example is provided in the first row of each of the three tables.

Table 1. Dermatologic Differential of Common Skin Lesions and Rashes

Name Cause Signs/Symptoms Diagnostics Treatment Concerns
Rocky Mountain Spotted Fever Tick bite Rickettsia rickettsii Fever, chills, severe headache, n/v, photophobia, myalgia, conjunctival injection, arthralgia; 2-5 days after onset – rash (petechiae) starts on hands/feet to trunk (palmar rash) Antibody titers to rickettsia
Punch biopsy
CBC, LFT, CSF Doxycycline 100mg BID for 7-14 days – can be fatal if not started on treatment within 8 days. Remove tick by grasping closest to skin and apply steady upward pressure Can be fatal (3-9%)
Highest in southeastern/south central regions of US Most common Apr – Sept
Erythema Migrans (Lyme disease) Meningococcemia
Varicella / Zoster
Malignant Melanoma
Basal Cell Carcinoma
Actinic Keratosis
Erythema Multiforme (Stevens-Johnson syndrome)

Table 2. Differential Diagnoses of Eye Emergencies

Name Cause Signs/Symptoms Diagnostics Treatment Concerns
Corneal Abrasion Trauma, foreign body, incorrect use of contact lenses Acute onset severe eye pain with tearing. Reports feeling of foreign body sensation Eye exam with Fluorescein dye Flush eye with sterile normal saline. Evert eyelid to look for foreign body. Topical antibiotic trimethoprim-polymyxin B (Polytrim),Ciprofloxacin (Ciloxan), Ofloxacin (Ocuflox) to affected eye 3-5 days.
Do not patch eye. Contact Lens-Related Keratitis – acute onset red eye, blurred vision, watery eyes, photophobia, foreign body sensation
Hordeolum (Stye)
Chalazion
Pinguecula
Pterygium
Subconjunctival Hemorrhage
Primary Open-Angle Glaucoma
Macular Degeneration

Table 3. Differential Diagnoses of Common Headaches

Name Signs/Symptoms Aggravating Factors Acute Treatment Prophylaxis
Migraine Without Aura Throbbing pain behind one eye, photophobia, N/V phonophobia, last 4-72 hr. Red wine, MSG, aspartame, menstruation, stress Ice pack on forehead, rest in dark quiet room
Triptans, Tigan suppositorie TCAs
Episodic migraine (<14 days per month) Beta-blockers Migraine With Aura Trigeminal Neuralgia (CN V) Cluster Muscle Tension PART 2: CASE STUDY Select one of the following case studies and corresponding Differentials Table to complete. In the subject line of your post, please identify which case study you are responding to. Select one of the following case studies. Complete the corresponding “Differentials Table” to align your clinical reasoning – include 5 differentials (excluding example provided). In SOAP format, discuss what questions you would ask the patient (Review of Systems), what physical exam elements you would include, what further testing you would want to have performed (if any), differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care. Upload your Differentials Table and SOAP note to the Discussion Board. Note: Document at least one scholarly source to connect your response to national guidelines and evidence-based research in support of your ideas. Case Studies Jenny, a 66-year-old retired cook, presents with a vesicular rash on the right side of her face. She experienced pain on that side 2 days ago, but thought it was just a headache. She has been under a lot of stress lately because she is caring for her husband who has Alzheimer’s disease. Sally is a 22-year-old female who recently became bothered by a rash that is itchy, red, inflamed, and dry. She also has scaly areas that she says are getting worse. The rash is only around her umbilicus and on her elbows. Both of her parents have psoriasis, but she doesn’t believe this is the problem, because it appears to be different from her parents’ lesions. She is living in Florida, is under a lot of stress in high school, and just recovered from a lingering upper respiratory infection (URI). A 48-year-old male presents with a two-month history of nighttime headaches that are becoming more frequent. The pain awakens him at night. He has no other somatic complaints and no other significant medical history. If you chose case study 1 or 2, complete the below Differentials Table Differential Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment Ex: Actinic Keratosis Scaling, dry, round, flesh-colored lesions on skin that do not heal; usually sunexposed areas; sizes range from microscopic to several centimeters. Clinical diagnosis For patients with multiple thin lesions on the face or scalp, treatment with topical fluorouracil cream is first-line therapy. Applied to AK lesions, fluorouracil cream causes inflammation and lesion necrosis. Inflammation typically subsides approximately two weeks after topical fluorouracil is discontinued. It typically takes four to six weeks (two to four weeks of which are active treatment) for the skin to progress through erythema, blistering, necrosis with erosion, and re-epithelialization. In patients with extensive AK, the treated area may become extremely inflamed. Thus, pretreatment patient information and education must be thorough to ensure adherence to treatment. Inflammatory response during treatment of AK with topical fluorouracil. 1. 2. 3. 4. 5. If you chose case study 3, complete the below Differentials Table. Differential Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment Ex: Temporal arteritis (giant cell arteritis/GCA) Unilateral pain, temporal area with scalp tenderness, skin over artery is indurated, tender, warm and reddened; amaurosis fugax (temporary blindness). Medical urgency – refer to ED or Ophthalmologist High dose steroids * Dose and route of administration of glucocorticoids for newly diagnosed GCA varies depending on whether patient presents with or without threatened or established visual loss at diagnosis. 1. 2. 3. 4. 5.