Differentials for the Patient’s Presenting Problems

QUESTION

I have had this itchy, scaly rash on my scalp and knees for 2 weeks. Because the rash is on my face, I do not want to go outside of my home because I feel other people are always staring at me. I have not been able to sleep, eat, or concentrate.”

History of Present Illness

K.B. is a 30 y.o. white female who presents to the office with a 2-week history of an itchy, scaly rash on both knees and scalp. She states she has had some rashes in the past but never as severe and never on her scalp. For the past 2 weeks she has not been able to sleep or to concentrate at work. When she gets home from work, she stays in the room alone.

Past Medical History

General Health: Hypertension, Allergic rhinitis

Immunizations: Up to date

Hospitalizations: Only hospitalized for childbirth

Surgeries: None

Obstetrics: G2P2

LMP: Total hysterectomy due to fibroid tumors

Medications: Lisinopril 20 mg daily, Loratadine 10 mg daily

Allergies: NKDA

Family History:

• Mother 52 has hypertension
• Father 53 alive and well
• Brother 32 has hypertension
• Sister alive and well
• Has one son 9 and one daughter 8, both alive and well

Social History: The patient lives with her husband and 2 children. She works for Regions Bank as a bank teller. She does not drink alcohol or smoke cigarettes. She denies any physical or mental abuse.

Review of Systems:

General: No weight loss or weight gain in the last year. No history of fatigue, fever, or chills.

Skin, Hair, and Nails: Has scaly rash on scalp and knees. No changes in any moles. Denies any problems or changes in hair or nails.

HEENT:

Head: Denies dizziness, lightheadedness, headaches. Eyes: Denies any eye pain or redness, does have tearing and itchiness. Denies blurred or double vision, does not wear contacts or glasses. Ears: Denies any ear pain, drainage. Nose: Has been having clear nasal drainage, congestion, sneezing, and itching. Denies any changes or problems with sense of smell. Throat: Denies any sore throats, vocal changes, masses, swelling, or difficulty swallowing. Denies any neck pain, masses or swelling; no swelling of thyroid gland.

Respiratory: Denies any SOB, dyspnea, wheezing or cough.

Breast: No history of breast tenderness masses or discharge.

Cardiovascular: Denies any chest pain, palpitations, history of rheumatic fever, hypertension. No problems with heart or edema in extremities.

Gastrointestinal: No complaints of nausea, vomiting, or abdominal pain.

Genitourinary/GYN: Denies any dysuria, hematuria, or history of UTIs. No history of urinary frequency.

Musculoskeletal: Denies any weakness, numbness, erythema, twitching, or pain. No joint pain, tenderness, or history of head trauma.

Peripheral Vascular: Denies swelling in face, hands, feet. No history of leg cramps.

Neurologic: Denies fainting, seizures, headaches, weakness or paralysis.

Psychological: Has not been able to sleep, eat, or concentrate for the past 2 weeks.

OBJECTIVE:

General Appearance: 30-year-old white female, alert and well groomed. Noted to have some silvery plaques to bilateral knees and frontal portion of scalp.

Vital Signs: BP 128/72 HR 70, RR 18, Temp. 98.7, HT 5’7ʺ, WT 168

Patient awake, alert, oriented x 4 in NAD

Skin: warm and dry to touch. Silvery plaques to bilateral knees and scalp

HEENT: head nontraumatic, normocephalic

Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted

Ears: bilateral TM with good cone of light and intact

Nose: mucosa pale and boggy, septum midline; no sinus tenderness appreciated

Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate. Post-nasal drip noted

Neck: supple; trachea midline; no LAD

Resp: regular and unlabored; lungs with end expiratory wheezing throughout

CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated

Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion

Genitalia: deferred

Rectal: deferred

Extremities: warm and without edema; calves supple, non-tender

PV: no LE edema

MS: MAEW

Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact

Address the following items:

1. List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.
2. At this time, what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?
3. What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?
4. What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.
5. What is your comprehensive plan of care? Include your rationales.

ANSWER

Differentials for the Patient’s Presenting Problems

1. Skin Rash on Scalp and Knees
Psoriasis: Psoriasis is a chronic autoimmune skin condition characterized by scaly, silvery plaques commonly found on the scalp and knees. It can be intensely itchy and affect daily activities.
Contact Dermatitis: Allergic reactions to certain substances can cause contact dermatitis, leading to scaly rashes. The patient’s description of itching may align with this diagnosis.
Seborrheic Dermatitis: This common skin condition can affect the scalp and produce scaly plaques. It can be exacerbated by stress, which the patient is currently experiencing.

2. Psychological Distress and Isolation
Major Depressive Disorder: The patient’s inability to sleep, eat, and concentrate for two weeks suggests a major depressive episode. This psychological condition can significantly impact daily functioning and social interactions.
Social Anxiety Disorder: The patient’s avoidance of going outside due to perceived scrutiny by others may be indicative of social anxiety disorder. It can lead to isolation and exacerbate depression.
Adjustment Disorder with Anxiety and Depressed Mood**: Given the recent stressor (severe skin condition), the patient may be experiencing an adjustment disorder, which can manifest as both psychological and physical symptoms.

Medical Diagnoses of Concern

Psoriasis: The primary concern is psoriasis, as it aligns with the patient’s skin symptoms. Psoriasis can significantly impact the patient’s quality of life, potentially exacerbating her psychological distress.
Major Depressive Disorder: Depression is a critical concern, as it affects the patient’s overall well-being, including sleep, appetite, and concentration. It may also exacerbate her skin condition.
Social Anxiety Disorder: If present, social anxiety may hinder the patient’s ability to engage in therapy or follow her treatment plan.
Adjustment Disorder with Anxiety and Depressed Mood: This diagnosis is of concern due to the recent onset of symptoms related to the stressor (skin condition).

Diagnostic Tests and Laboratory Work

1. Skin Biopsy: To confirm or rule out psoriasis or other skin disorders.
2. Complete Blood Count (CBC): To assess for anemia, which can be associated with psoriasis and depressive disorders.
3. Liver Function Tests (LFTs): Elevated LFTs can be indicative of psoriasis, especially if systemic treatment is considered.
4. Thyroid Function Tests (TSH, Free T4): Thyroid dysfunction can mimic symptoms of depression and may exacerbate skin conditions.
5. Depression Screening Questionnaires (e.g., PHQ-9): To assess the severity of depressive symptoms.
6. Anxiety Assessment (e.g., GAD-7): To evaluate the presence and severity of anxiety symptoms.
7. Referral to Dermatology: A dermatologist can provide a definitive diagnosis and recommend appropriate treatment for the skin condition.

Comprehensive Plan of Care

1. Psoriasis Management
Treatment may include topical corticosteroids or phototherapy as an initial step.
If needed, systemic medications like methotrexate or biologics can be considered.
Regular follow-up with a dermatologist for ongoing evaluation and adjustments.

2. Depression and Anxiety Management
Referral to a mental health specialist for counseling and therapy.
Consideration of antidepressant medication if symptoms are severe or not responsive to therapy.

3. Social Support and Coping Strategies
Encourage the patient to engage with support groups or therapy to address psychological distress.
Provide education on stress management and coping techniques.

4. Regular Follow-Up
Frequent follow-up appointments to monitor treatment effectiveness and adjust interventions as needed.
Collaboration between dermatology and mental health providers to address both physical and psychological aspects of care.

In conclusion, a comprehensive approach is necessary to address the patient’s skin condition, psychological distress, and social isolation. Collaborative care involving dermatology and mental health specialists is crucial to achieve optimal outcomes. Monitoring the patient’s progress and adjusting the treatment plan as necessary is essential to ensure her well-being and recovery.