NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning

Comprehensive SOAP Document: Skin Condition Sample Paper

Patient’s Initials: __WP__. Age:__ 54 ___ Gender: Male.

SUBJECTIVE DATA: Graphic#2

Chief Complaint (CC): Painful and itchy blisters on the back and right arm for one week (image #2).

History of Presenting Illness (HPI): A 54-year-old Caucasian male patient presents with blisters and ulcers on his torso extending all the way to his upper right arm. There are multiple blisters that appear shiny in colour. There is also an erythematous region surrounding the blisters. The condition started about a week ago with a painful burning and tingling sensation around the same region before the appearance of the rash. This was accompanied by fever and generalised body weakness. The rash later appeared four days after the initial tingling and burning sensation. The patient said that the condition had no aggravating factors but that it was relieved by taking a cool bath.

Past Medical History: The patient has no known chronic illnesses and has no history of previous admissions. The patient has never undergone any surgical procedures and has no prior history of blood transfusion. The patient has no known drug and food allergies.

Family Social History: There are no known chronic illnesses among close family members. The patient leads a sedentary lifestyle. He is an occasional drinker claiming that he drinks a glass of wine every now and then. He denies any tobacco use or use of any other drugs and substances.

REVIEW OF SYSTEMS

General: complains of generalised body weakness

HEENT: The patient complains of occasional headaches during the one-week period that he has been unwell. He also complains of sensitivity to light

Neck; no lymphadenopathy or goitre

Respiratory: no cough, wheezing, shortness of breath

CVS: no chest pain, dyspnea, orthopnea or oedema.

GIT: no nausea, vomiting, constipation or diarrhea

Skin: no bruising, petechiae or changes in hair.

General Examination: The patient has hotness of body. There are several painful blisters and erythematous regions around his torso and upper arm. There is no significant weight loss and no apparent signs of wasting. There is no jaundice, no pallor, no cyanosis, no clubbing no lymphadenopathy, no oedema and no dehydration.

OBJECTIVE DATA:

Physical examination:

Vitals: The patient has a blood pressure reading of 134/83. His heart rate is 86 beats per minute with a respiratory rate of 16 breaths per minute. His temperature reading is 99.7 F indicating a slight fever. The patient weighs 179 pounds with a height of 5ft. 10 in. The patient’s Body Mass Index (BMI) is 25.7 indicating that the patient is slightly obese which is evident even on examination.

General: Middle-aged man who is alert and oriented to time place and person. The patient is conscious, alert and co-operative. The patient is not in any apparent respiratory distress. He is well groomed and tidy in a hospital gown. He does not seem to be in any apparent pain, though he is constantly scratching his back. The patient has no odour coming from his mouth and he has good oral hygiene. He does not have any tar stains on his fingers or clothes.

Skin: The patient as several shiny blisters and erythematous rash on his torso extending all the way to the arm that are painful and itchy. The blisters appear shiny and fluid-filled. The rash on the other hand is erythematous and maculopapular with ulcerations and scabbing. There are also several regions of hyperpigmentation.

ASSESSMENT.

Differential diagnosis: Herpes Simplex Virus (HSV) Infection, hives, psoriasis and eczema.

Herpes Simplex Virus (HSV) is virus that commonly reactivates throughout an individual’s life and results from herpes simplex virus 1 and 2. The blisters commonly observed in this condition may be mistaken for those of shingles (Fathy et al., 2021). However, the blisters in this condition are commonly localized around the oral and genital regions. Shingles when compared to herpes also takes a longer duration of time to resolve.
Hives, also commonly referred to as urticaria, is a skin rash often triggered in response to certain foods, medication or other irritants. The condition, according to Greiwe and Bernstein (2019), is normally characterized by the appearance of raised erythematous or skin-coloured welts that tend to be itchy appearing on the surface of the skin. The condition is often a self-diagnosable and self-treatable one that rarely requires any laboratory investigations or imaging. The welts tend to resolve within a few days or weeks.
Psoriasis is described as a condition in which the cells of the skin tend to build up resulting in the formation of scaly and dry patches that tend to be itchy. In severe instances, the rash may involve both the nails and joints (Armstrong & Read, 2020). The skin also tends to be dry, flaky, has bumps and easily peels off. Patients will commonly present with depression, inflamed tendons, stiffness and possessing dents in their nails. Topical ointments, light therapy and medications have been used in the management of psoriasis.
Eczema or atopic dermatitis is a condition that causes and individual’s skin assume a dry, erythematous and bumpy appearance that tends to be itchy. The condition disrupts the barrier tendencies of the skin resulting in increased sensitivity and increasing the likelihood of both infections and drying off (Ring et al., 2019). Regularly moisturization of the skin, medication and habits aimed at protecting the skin such as the use of soap with little or no perfumes and dyes are vital in the management of eczema.

Primary Diagnosis: The most likely diagnosis for the graphic provided is shingles. Shingles can be described as a reactivation of the chicken pox virus that commonly results in the appearance of a painful rash. As Fritz et al. (2020) notes, shingles often leads to the appearance of a painful and itchy rash that tends to appear as a collection of several pus-filled blisters on the torso of the affected individual. This painful sensation tends to persist, in some instances, even after the resolution of the rash.

The initial symptoms usually reported include fever and generalized body weakness. The patient may also experience a painful, burning or tingling sensation around certain areas. This is usually followed by the appearance of rashes a few days after the initial presentation of the tingling sensation (Bolton et al., 2021). The patient tends to notice the appearance of erythematous patches, mostly on one side of the body. Blisters, scabs and ulcers follow the initial presenting rash.

In some instances, patients may develop ophthalmic shingles. In this condition, there is appearance of shingle rashes in the region around the eye and above the forehead. This condition is commonly accompanied by a complaint of occasional headaches. Inflammation of the cornea and swelling of the eye may also be evident (Battista et al., 2020). Widespread shingles may be observed in individuals with extremely weakened immune systems. Widespread rashes resembling chicken pox are commonly observed in this condition.

According to Bakker et al. (2021), shingles commonly develops in individuals who have previously had chicken pox that has consequently resolved. The virus responsible for the causation of both chicken pox and shingles can, however, be transmitted to and individual who has never suffered chicken pox or received the chicken pox vaccine. In such instances, the individual develops chicken pox instead. Transmission of shingles occurs during the blister phase of the rash (Laing et al., 2018). Transmission is through direct contact of the rash or inhalation of virus particles that are released into the air.

In most instances, the condition normally resolves on its own. There are several antiviral drugs that have been employed in the treatment of shingles. Some of these agents include acyclovir, valacyclovir and famciclovir. As Nazarko (2019) notes, the use of these medication during the early stages of appearance of the rash greatly reduces the severity of the condition and reduces the duration of illness. Pain medication to counter the intense pain may also be recommended by the health care practitioner.

Conclusion

In conclusion, both the appearance and the location of the rash confirm the diagnosis of shingles. The rash is localized in the patient torso on the posterior surface and his right arm. The rash is erythematous and comprises of several shiny pus-filled blisters confirming the diagnosis of shingles. As previously noted, the blister phase of the rash is the most infective stage of the condition. Thus, it is paramount to immediately commence the management of the patient’s conditions so as to offer relief to him by reducing both the severity and duration of his condition, while still reducing the risk of him transmitting to others. Antiviral medication and the use of analgesics to manage the pain go a long way in managing the patient’s condition.

References.

Armstrong, A. W., & Read, C. (2020). Pathophysiology, clinical presentation, and treatment of psoriasis: a review. JAMA, 323(19), 1945-1960. https://doi.org/10.1001/jama.2020.4006

Bakker, K. M., Eisenberg, M. C., Woods, R., & Martinez, M. E. (2021). Exploring the seasonal drivers of varicella zoster transmission and reactivation. American Journal of Epidemiology, 190(9), 1814-1820. https://doi.org/10.1093/aje/kwab073

Battista, M., Marchese, A., Bordato, A., Bandello, F., Modorati, G. M., & Miserocchi, E. (2020). Ophthalmic Shingles with Simultaneous Acute Retinal Necrosis in the Opposite Eye. Ocular Immunology and Inflammation, 1-3. https://doi.org/10.1080/09273948.2020.1770298

Bolton, L. L., Faller, N., & Kirsner, R. S. (2021). Herpes Zoster (Shingles) Patient-Centered Wound Outcomes: A Literature Review. Advances in Skin & Wound Care, 34(5), 239-248. https://doi.org/10.1097/01.asw.0000737412.71091.4f

Fathy, R. A., McMahon, D. E., Lee, C., Chamberlin, G. C., Rosenbach, M., Lipoff, J. B., Tyagi, A., Desai, S. R., French, L. E., Lim, H. W., Thiers, B. H., Hruza, G. J., Fasset, M., Fox, L. P., Greenberg, H. L., Blumenthal, K. & Freeman, E. E. (2021). Varicella Zoster and Herpes Simplex Virus Reactivation Post‐COVID‐19 Vaccination: A Review of 40 Cases in an International Dermatology Registry. Journal of the European Academy of Dermatology and Venereology. https://doi.org/10.1111/jdv.17646

Fritz, D. J., Curtis, M. P., & Kratzer, A. (2020). Shingles. Home Healthcare Now, 38(5), 282-283. https://doi.org/10.1097/nhh.0000000000000905

Greiwe, J., & Bernstein, J. A. (2020). Approach to the Patient with Hives. The Medical clinics of North America, 104(1), 15–24. https://doi.org/10.1016/j.mcna.2019.08.010

Laing, K. J., Ouwendijk, W., Koelle, D. M., & Verjans, G. (2018). Immunobiology of Varicella-Zoster Virus Infection. The Journal Of Infectious Diseases, 218(suppl_2), S68–S74. https://doi.org/10.1093/infdis/jiy403

Nazarko, L. (2019). Diagnosis, treatment and prevention of shingles: the role of the healthcare assistant. British Journal of Healthcare Assistants, 13(1), 20-25. http://dx.doi.org/10.12968/bjha.2019.13.1.20

Ring, J., Zink, A., Arents, B., Seitz, I. A., Mensing, U., Schielein, M. C., Wettemann, N., de Carlo, G., & Fink-Wagner, A. (2019). Atopic eczema: burden of disease and individual suffering – results from a large EU study in adults. Journal of the European Academy of Dermatology and Venereology: JEADV, 33(7), 1331–1340. https://doi.org/10.1111/jdv.15634