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Introduction

As a future APRN you must be able to identify clinical manifestations and use the pathophysiological processes to critically think through various patient situations with both children and adults. These steps will help you develop pathways to establish differential diagnoses that ultimately lead to your final treatment plan.

We will start by completing several branching scenarios. In the following scenarios, you will meet four patients. After you meet with your patients, you will choose one case to discuss further. Please print or save the summary for the patient case you have chosen. You will be using this information to complete the assignment this week.

Choose a branching scenario.

Now that you have met with all four patients, choose a case and either print or save their patient information. You will use this information to complete and submit this week's assignment.

Jacob Martin

You are the APRN staffing the health clinic. A mom brings in her 9-month-old son, Jacob, into the clinic. He presents with dry, red, and excoriated patches of skin on his cheeks and extensor elbow surfaces. Some of these areas have clear fluid drainage.

As a nurse practitioner, what is the first thing you do?

You are not sure how to proceed, so you refer Jacob and his mother to a specialist.

The mother becomes frustrated as Jacob begins to cry. His discomfort is increasing and the situation is quickly degrading. You may want to rethink your approach.

As an APRN, your goal is to provide quality care for your patients. You should only refer the patient to a specialist if you cannot or do not know how to provide care. Please try again.

Ask the mother about family history of allergies or asthma.

The mother replies she is not aware of Jacob having any allergies but does report that Jacob’s father has severe asthma and Jacob's maternal grandmother has a history of allergic rhinitis.

What do you do next?

You report to Jacob's mother that nothing is wrong. You let her know it is just a minor rash, which is normal for his age. You send them home.

Jacobs Mother is not happy with that answer and asks for a second opinion.

Your goal is to provide help and options for this family. Please try again.

You tell the mother that since Jacob does not have allergies, it is probably just a transient non-serious rash, no action is needed, and she may take Jacob home.

Jacob's mother apologizes and tells you she forgot to mention that Jacob does have asthma, like his father.

You may have acted too quickly. Be sure you take time to ask the right questions. Jacob's mother mentioned his father having asthma, but she never confirmed or denied this condition with Jacob. Please try again.

This condition is concerning, so you decide to order labs immediately.

You order labs, but they do not provide any important information and add cost for the mother.

The goal is to provide quality care while minimizing costs to the patient and their family. Given everything we know, lab work is not needed at this time. Please try again.

You decide to ask Jacob's mother several more questions.

The mother replies she is not aware of Jacob having any allergies but does report that Jacob’s father has severe asthma and Jacob's maternal grandmother has a history of allergic rhinitis.

What do you do next?

You ask the mother if the Jacob also has asthma or if he has been diagnosed with allergic rhinitis in the past.

The mother reports Jacob, like his father, also has asthma. She reports Jacob has not had any symptoms of allergic rhinitis in the past.

At this point, you believe you have enough information to diagnose this condition as atopic dermatitis.

You ask Jacob's mother what types of soaps and detergents she is using at home.

Although these are good questions to ask, Jacob's mother has already reported he has no known allergies.

Focus on pathophysiology to help you understand the patient's condition. You may not have all the family or patient history needed to make a solid determination on Jacob's condition. Please try asking a few more questions before you rule anything out or jump to another conclusion. Please try again.

Based on this diagnosis, discuss the underlying pathophysiology, including genetic factors, immune system factors, interactions of the neurologic and immune systems, and alterations of the skin microbiome. Discuss its clinical manifestations.

Type in your first and last name. Then slect Submit. Your results will display with instructions on how to download and save your file as a PDF document.

Ella Jorden

You are the APRN on staff at the clinic when a father arrives with his 8-year-old daughter, Ella. You immediately notice that Ella's father appears to be extremely worried. Ella appears to be quite uncomfortable and whimpers that she is really itchy.

As a nurse practitioner, what is your first step?

Ask Ella where she is itchy and ask her to show you.

Ella flinches as she rolls up the sleeves of her shirt. You notice raised, flesh-colored papules with indented centers on the patient’s arms. As you continue your visual examination, you notice the same thing on her back and legs as well.

What is your next step?

You decide to ask Ella and her father more questions.

What will you as Ella and her father?

You ask Ella if any of her friends at school are itchy like she is.

Ella reports that her friend Stephanie, who is on her soccer team, is also very itchy.

What is your next step?

Ask the father if Ella and Stephanie have spent time together recently.

Ella's father states that outside of soccer, Ella and Stephanie often hang out together on the weekends and that they had a sleepover two weeks ago.

Based on what you have learned about Ella's medical history and the physical exam you conducted, you have diagnosed Ella with molluscum contagiosum.

Tell the father that there is nothing to be concerned about and to provide Ella with Benadryl and keep an eye on her for 24 hours.

Ella's father gets upset over the fact that his family paid for this visit only to be advised to use Benadryl.

As a provider, you will want to provide a higher level of care for Ella. Please try again.

Pull up Ella's past medical records.

Although this may seem like a good place to start, it is important that you create your own records. Not every record is perfect and with this type of interaction, it is crucial that you have the facts straight and are aware of any updates or changes with the patient. Please try again.

You diagnose Ella with varicella-zoster virus, or chickenpox.

Although at this point, it may appear that Ella has chickenpox, you do not have enough information to make this determination. Please try again.

Tell Ella's father you are not sure what the issue is and encourage him to take Ella to see a dermatologist.

Ella's father looks disappointed and worried as he asks you if there is anything you can do to help his daughter.

As a care provider, you want to provide your patients with quality care, referring them to specialists only when you have exhausted all other options.

If Ella is sent to the dermatologist at this point, it will simply become another expense and will get Ella and her father no closer to resolving the problem. Please try again.

You ask Ella's father if she has had chickenpox or the immunization for chickenpox.

Ella's father replies, stating that Ella had the chickenpox last fall.

This was a good question and has gotten you closer to figuring things out. Let's keep moving.

Ask Ella if she knows why Stephanie is itchy.

Ella looks at you and shrugs her shoulders.

She is not sure why Stephanie is itchy. Please try again.

Based on this diagnosis, discuss the risk factors, the underlying pathophysiology, the clinical manifestations, and the course of the infection.

Type in your first and last name. Then slect Submit. Your results will display with instructions on how to download and save your file as a PDF document.

Mrs. Lee

You are the APRN on staff at the clinic one evening when Mrs. Lee arrives complaining of skin irritation.

As the APRN on staff, what is your first step?

Conduct a visual examination of the areas of concern.

You notice symmetric areas of silvery scale overlying red plaques on her elbows and her scalp.

What do you do next?

Conduct a visual examination of the areas of concern.

You notice symmetric areas of silvery scale overlying red plaques on her elbows and her scalp.

What do you do next?

Mrs. Lee responds that her sister has psoriatic arthritis. Mrs. Lee also reports noticing redness, swelling, and pain in various joints.

This is a very important question to ask and has gotten you one step closer to helping Mrs. Lee. We still need a bit more information before we can move forward.

Try asking Mrs. Lee a few more questions.

Mrs. Lee reports that both of her parents have been diagnosed with psoriasis and has suspected that this may be her issue as well.

Mrs. Lee gives you a nervous look as you tell her that she is experiencing a psoriasis flare.

Based on the information provided, you have been able to determine that Mrs. Lee is experiencing a psoriasis flare.

Let Mrs. Lee know that you are not a dermatologist, but you can refer her to a wonderful specialist.

Mrs. Lee gives you a frustrated look as she says, "you are my primary care provider. If you are referring me, does that mean I need to pay for this visit?"

As Mrs. Lee's primary care provider, it is your responsibility to provide the best care possible. There are a few more things you can do before you refer to specialist. This becomes and extra cost. Please try again.

You ask Mrs. Lee if she has a family or personal history of asthma, allergic rhinitis, or atopic eczema (atopic dermatitis).

Mrs. Lee, itching her arm, replies that her family has no personal history with any of those issues.

These are great questions and can help you to either determine or rule out certain issues. In this case, we can move forward with additional questions. Keep asking Mrs. Lee about what she is experiencing.

Based on this diagnosis of plaque psoriasis, discuss the risk factors, including genetic and other factors, the underlying pathophysiology of the disease, its clinical manifestations, and associated comorbidities.

Type in your first and last name. Then slect Submit. Your results will display with instructions on how to download and save your file as a PDF document.

Kyle Thompson

While you are on shift at the clinic, 65-year-old Kyle Thompson arrives complaining of a skin change on the right side of his face.

You are the only APRN on staff at the clinic. What is the first thing you do? 

Ask Kyle when he first noticed this skin change.

Kyle reports that this change came on fairly suddenly.

With this being a new and sudden development, there are a few more steps that need to be taken before you can determine Kyles condition.

Conduct a visual examination.

During your visual examination, you notice an ulcerated flesh-colored papule on the right side of his face.

What is your next step?

Ask if he has had this checked out in the past.

Kyle reports this is the first time he has seen a medical professional but mentions that his wife thinks it may be something serious.

Since this is the first time he is being seen, there are a few steps you will want to take.

You perform dermoscopy of the lesion.

The results of the dermoscopy show a spidery-appearing blood vessel on the papule’s surface.

What is your next step?

Ask Kyle where he has lived during his life.

Kyle tells you that he grew up in Hawaii and that his dad was in the military. He lived on Maui for most of his life before moving to Florida last spring.

What is your next step?

Ask Kyle about his hobbies and what he likes to do in his free time.

He gives you a puzzled look and then tells you he enjoys fishing, boating, and surfing during his free time. He continues to tell you how much he enjoys the outdoors. Living in Hawaii and Florida his entire life, he has gotten plenty of time to have fun in the sun.

Based on the information Kyle provided, what is your next step?

Ask Kyle about his family medical history.

Kyle reports that his family is pretty healthy, but that his father was diagnosed with squamous cell carcinoma and basal cell carcinoma about 10 years ago.

At this point, you have made the presumptive diagnosis of basal cell carcinoma and have referred the patient to a dermatologic specialist.

You order a biopsy for the area of concern.

A skin biopsy may not be the best course of action at this point. Once you have more information on Kyle's condition, you can make a better determination on how to proceed.

You tell Kyle that you must refer him to a dermatologic specialist.

Kyle may need to see a specialist at some point, but for now, you are still not sure of Kyle's condition. See if you can get more information before you refer him elsewhere. Please try again.

You tell Kyle that you must refer him to a dermatologic specialist.

Kyle tells you that he has to make it across town soon for another appointment and asks why you are asking these questions.

You tell Kyle that these questions help you better understand what may be happening with his skin condition. You ask him if you may ask a few more questions and he replies, "yes".

You ask Kyle how much sunscreen he wears.

Kyle nervously laughs as he tells you that he has gotten much better with wearing sunscreen, but tells you that when he was a kid, sunscreen was not popular.

Keep asking Kyle questions. You almost have all the info you need.

Based on the presumptive diagnosis of basal cell carcinoma, discuss the risk factors, the pathogenesis of basal cell carcinoma, including how the two are interrelated. Please discuss the various clinical manifestations.

Select the Print button to print or save a copy of this document. Your browser’s print window will then appear. To save as a PDF document, select Adobe PDF in the Select Printer (Firefox) or Destination (Chrome) options. Then, select Print to save this document as an Adobe PDF document to your computer.

You will use this information to complete and submit this week's assignment.

Jacob Martin

Jacob Martin

You are the APRN staffing the health clinic. A mom brings in her 9-month-old son, Jacob, into the clinic. He presents dry, red, and excoriated patches of skin on his cheeks and extensor elbow surfaces. Some of these areas have clear fluid drainage.

After seeing Jacob and his mother, you diagnosed Jacob with atopic dermatitis.

Ella Jorden

Ella Jorden

You are the APRN on staff at the clinic when a father arrives with his 8-year-old daughter, Ella. You immediately notice that Ella's father appears to be extremely worried. Ella appears to be quite uncomfortable and whimpers that she is really itchy.

After meeting with Ella and her father, you diagnosed Ella with molluscum contagiosum.

Mrs. Lee

Mrs. Lee

You are the APRN on staff at the clinic one evening when Mrs. Lee arrives complaining of skin irritation.

After your visit with Mrs. Lee, you determined that she is experiencing a psoriasis flare.

Kyle Thompson

Kyle Thompson

While you are on shift at the clinic, 65-year-old Kyle Thompson arrives complaining of a skin change on the right side of his face.

After examining Kyle, you were able to diagnose him with basal cell carcinoma.

Activity is complete.