Value: 100 points
Due: Day 7
Gradebook Category: Assignments—Comprehensive Case Study
For this assignment, you will be electronically completing an interactive case study. You will progress through a patient case much like you would in practice. You will need to make decisions for your patient as you complete the case and provide rationale for your answers and decisions. You will have one attempt to complete this assignment, which must be completed in one sitting.
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Please refer to the Grading Rubric for details on how this activity will be graded.
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Differential Diagnoses
Atopic Dermatitis with impetigo is a chronic inflammatory condition characterized by pruritis and erythematous macules, papules, and vesicles that can weep or crust (Dains et al., 2020; Howe, 2022). Atopic dermatitis is more frequently found in children than adults (Howe, 2022). In children it most often presents as patches of erythema to flexural surfaces (Frazier & Bhardwaj, 2020). Atopic dermatitis is the most likely diagnosis for this patient as they present with hallmark manifestations such as severe pruritus and dry skin (Howe, 2022). Scaly erythematous lesions and Dennie-Morgan infraorbital folds are also common findings (Howe, 2022). These episodes first occurred when he was 4 years old which is also consistent with atopic dermatitis which presents before the age of 5 years in 85% of cases (Howe, 2022). He also has risk factors for atopic dermatitis such as a family history of atopy – father with eczema and asthma, and a sister with allergic rhinitis (Howe, 2022). Children that have a parent with atopy have an increased risk of developing atopic dermatitis (Howe, 2022). The patient’s course of remission and relapsing symptoms is also consistent with atopic dermatitis (Howe, 2022). The patient meets the following diagnostic criteria for atopic dermatitis: pruritus, eczema with flexural lesions, relapsing pattern, a personal and/or family history of atopy, and an early age of onset (Frazier & Bhardwarj, 2020; Howe, 2022). Diagnosis is typically based on history and clinical findings and laboratory tests and skin biopsy is not typically indicated (Howe, 2022).
Contact Dermatitis is characterized by skin inflammation due to direct contact between the skin surface and a substance (Levy, 2022). This is a possible diagnosis for the patient because he presents with erythema with exudate and pruritus (Dains et al., 2020). The patient does not have occupational or hobby related exposures or risk factors for contact dermatitis (Dunphy et al., 2019; Yiannias, 2021). Contact dermatitis is most commonly diagnosed based on clinical manifestations, exposure history, and patch testing (Yiannias, 2021). Contact dermatitis is also less likely because the rash does not have an asymmetrical lesion distribution and the patient does not have lesions in the gluteal, axillary, or groin area (Dunphy et al., 2019).
Psoriasis is a chronic autoimmune disorder and inflammatory skin condition that has a remitting and relapsing pattern (Feldman, 2022; Paller & Lund, 2022). Psoriasis is also characterized by pruritic scaly erythematous patches that can present at the knees, elbows, and/or flexural areas (Paller & Lund, 2022). However, it is less likely as the patient does not have lesions in the gluteal, axillary, or groin area (Howe, 2022). The patient does not have known risk factors for psoriasis such as family history of psoriasis, or behavioral/environmental factors such as obesity, alcohol use, or smoking (Feldman, 2022). In children, psoriasis commonly involves the scalp and may involve the face (Feldman, 2022). Psoriasis is also less likely the diagnosis for this patient because it usually is less pruritic than atopic dermatitis (Paller & Lund, 2022). Psoriasis is typically diagnosed by physical examination in most patients (Feldman, 2022). In certain difficult cases a skin biopsy can help with diagnosis, but it is typically not necessary (Feldman, 2022).
Seborrheic Dermatitis should also be considered as a differential diagnosis because it is another chronic skin condition characterized by a remission and relapsing pattern (Sasseville, 2022). It is also a condition that presents with pruritic scaling erythematous patches that tends to be worse in the wintertime (Dains et al., 2020). This diagnosis is less likely as the patient does not have lesions in the gluteal, axillary, groin area, torso or scalp (Dains et al., 2020; Howe, 2022). Seborrheic dermatitis is diagnosed based on clinical manifestations, physical examination and location of lesions (Sasseville, 2022). Biopsy can also be used if diagnosis is uncertain but it not typically necessary (Sasseville, 2022).
Final Diagnosis: Atopic dermatitis with impetigo
Plan
Labs/Diagnostics
Not indicated at this time
Pharmacology
Cetirizine OTC 5-10 mg by mouth once daily as needed for itching (Lexicomp, n.d.-a)
Mupirocin 2% topical cream TID for 10 days apply to elbow infection (William, 2022).
Tacrolimus 0.03% topical ointment BID apply to rash for 2-4 weeks (William, 2022)
Tacrolimus can be used to treat moderate to severe atopic dermatitis; it can also be used along with a topical corticosteroid (Frazier & Bhardwaj, 2020).
Triamcinolone acetonide 0.025% topical ointment apply BID to rash (Frazier & Bhardwaj, 2020; William, 2022)
If first-line topical steroid is not effective, a medium to high strength topical steroid can be used twice a day (Frazier & Bhardwaj, 2020).
When used as proactivie therapy for individuals with frequent flares: after flare resolves, apply twice a week for 2 consecutive days for up to 16 weeks (William, 2022).
Non-pharmacology
At least twice a day and immediately after bathing liberally apply a low water content emollient such as Cetaphil or petroleum jelly to keep skin hydrated (Dunphey et al., 2020; William, 2022).
For bathing use soap free cleansers or mild soap (William, 2022).
Consults/Referrals
Consider dermatology referral if atopic dermatitis is resistant to treatment
Patient Education
Your child has been diagnosed with atopic dermatitis which is a chronic inflammatory skin condition that presents in a relapsing and remitting pattern (Frazier & Bhardwaj, 2020).
Your child also has impetigo to his elbow which is a type of skin infection that can cause itching lesions (Dunphy et al., 2020).
A topical antibiotic ointment called Mupirocin has been prescribed to treat the skin infection on the elbow (Lexicomp, n.d.-b).
Using a cotton swab or gauze, apply a small amount of ointment to the affected area. Wash hands after applying medication and avoid contact with the eyes (Lexicomp, n.d.-b).
Possible side effects of Mupirocin, Tacrolimus, and triamcinolone acetonide includes itching, stinging or burning at the site – if you experience any of these side effects notify your provider (Frazier & Bhardwaj, 2020; Lexicomp, n.d.-b).
Apply a thin film of triamcinolone acetonide topical ointment to the rash; use sparingly (Frazier & Bhardwaj, 2020).
For bathing you should use soap free cleansers or mild soap (William, 2022).
Avoid excessive bathing which can dry skin out further and after bathing you should immediately apply moisturizer (Dunphy et al., 2020).
To help maintain skin hydration especially during dry climates and cold weather you can use a humidifier (Dunphy et al., 2020).
Follow Up
Schedule a 2 week follow up to evaluate effectiveness of treatment (William, 2022)
You should follow up in 5 days with your provider if the elbow infection is not improving (Lexicomp, n.d.-b).
Notify your provider if your child experiences any new or worsening symptoms.
Health Maintenance: A health maintenance practice to help decrease risk of flare ups and minimize irritation is to apply a mild emollient at least twice a day. Even during remission phases this should be done to help maintain skin hydration and prevent dry skin (William, 2022).
Social Determinant of Health: The patient is a child and therefore it is important to include both the patient and his mothers in the plan of care and provide education to everyone. I can help address this by including both the patient and his mothers in discussions and when educating them on managing the patient’s atopic dermatitis.
References
Dains, J.E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.
Dunphy, L., Vinland-Brown, J., Porter, B., & Thomas, D. (2019). Primary care: Art and science of advanced practice nursing – An interprofessional approach. (5th ed.). Philadelphia, P.A., F.A. Davis.
Feldman, S. R. (2022). Psoriasis: Epidemiology, clinical manifestations, and diagnosis. UpToDate. Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/psoriasis-epidemiology-clinical-manifestations-and-diagnosis?search=psoriasis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Frazier, W., & Bhardwaj, N. (2020). Atopic dermatitis: Diagnosis and treatment. American Family Physician, 101(10), 590-598. https://eds-p-ebscohost-com.regiscollege.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=5&sid=cb438909-d45a-429a-9855-9cb9f364cec3%40redis
Howe, W. (2022). Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis.UpToDate. Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/atopic-dermatitis-eczema-pathogenesis-clinical-manifestations-and-diagnosis?search=atopic%20dermatitis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=2#H15
Levy, M. L. (2022). Contact dermatitis in children. UpToDate.Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/contact-dermatitis-in-children?search=contact%20dermatitis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Lexicomp. (n.d.-a). Cetirizine (systemic): Drug information. UpToDate.Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/cetirizine-systemic-drug-information?source=auto_suggest&selectedTitle=1~2—2~3—zyrtec%20dosing&search=zyrtec%20systemic#F50183081
Lexicomp. (n.d.-b). Mupirocin: Pediatric drug information. UpToDate. Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/mupirocin-pediatric-drug-information?search=mupirocin%20topical&topicRef=9668&source=see_link
Paller, A. S., & Lund, E. B. (2022). Psoriasis in children: Epidemiology, clinical manifestations, and diagnosis. UpToDate.Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/psoriasis-in-children-epidemiology-clinical-manifestations-and-diagnosis?search=psoriasis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Sasseville, D. (2022). Seborrheic dermatitis in adolescents. UpToDate.Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/seborrheic-dermatitis-in-adolescents-and-adults?search=seborrheic%20dermatitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
William, H. (2022). Treatment of atopic dermatitis (eczema).UpToDate. Retrieved March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/treatment-of-atopic-dermatitis-eczema?search=atopic%20dermatitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Yiannias, J. (2021). Clinical features and diagnosis of allergic contact dermatitis. UpToDate. Received March 19, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/clinical-features-and-diagnosis-of-allergic-contact-dermatitis?search=contact%20dermatitis&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4#H111504337
Comprehensive Case Study Rubric
CriteriaExemplary
Exceeds ExpectationsAdvanced
Meets ExpectationsIntermediate
Needs ImprovementNovice
InadequateTotal PointsApproach to Patient CareApproach to patient care is organized, logical, patient-centered, and cost effective, with 0 errors.
10 pointsApproach to patient care is organized, logical, patient-centered, and cost effective, with 1–3 minor errors or 1 major error.
7 points
Approach to patient care is organized, logical, patient-centered, and cost effective, with 4–6 minor errors or 2 major errors.
5 pointsApproach to patient care is organized, logical, patient-centered, and cost effective, with 6+ minor errors or 2+ major errors.
3 points10Differential Diagnoses (Including Problems)All required differential diagnoses and problems are included (including worst case) and fully supported by findings.
Rationale for all differential diagnoses provided.
20 points
Most required differential diagnoses and/or problems are included (including worst case); one is not supported by findings.
Rationale for most differential diagnoses provided.
18 pointsSome required differential diagnoses or problems are included (not including worst case); two are not fully supported by findings.
Rationale for some differential diagnoses provided.
14 pointsFew required differential diagnoses or problems are included; more than two are not fully supported by findings.
Rationale provided for few differential diagnoses.
9 points20Case Specific questions and RationaleLogical and systematic organization of data.
Rationale provided for all answers and decisions made regarding patient care. Rationale is based on current evidence, with 0 errors.
Correct terminology, spelling, and grammar.
20 points
Logical and systematic organization of data.
Rationale provided for most answers and decisions made regarding patient care. Rationale is based on current evidence, with 1–3 minor errors or 1 major error.
Terminology, spelling or grammar errors (1–3).
15 pointsMinor errors in organization of data.
Rationale provided for some answers and decisions made regarding patient care. Rationale is based on current evidence, with 4–6 minor errors or 2 major errors.
Terminology, spelling, or grammar errors (4–6).
11 points
Disorganized flow of data.
Rationale provided for few answers and decisions made regarding patient care. Rationale is based on current evidence, with 6+ minor errors or 2+ major errors.
Terminology, spelling, or grammar errors (>6).
6 points20PlanComprehensive plan includes all components with no errors: Diagnostic testing Pharmacologic intervention Nonpharmacologic intervention Referrals Follow-up
50 points
Plan missing 1 of the identified components or plan is based on current evidence, with 1–3 minor errors or 1 major error.: Diagnostic testing Pharmacologic intervention Nonpharmacologic intervention Referrals Follow-up
40 pointsPlan missing 2 of the identified components or plan is based on current evidence, with 4–6 minor errors or 2 major errors.: Diagnostic testing Pharmacologic intervention Nonpharmacologic intervention Referrals Follow-up
30 pointsPlan missing >3 of the identified components and/or has safety Concerns or is based on current evidence, with 6+ minor errors or 2+ major errors.: Diagnostic testing Pharmacologic intervention Nonpharmacologic intervention Referrals Follow-up
20 points
50Total Points100
