Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK 6 TD2 Dermatologic And Musculoskeletal Disorders Discussion Part Two

Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK 6 TD2 Dermatologic And Musculoskeletal Disorders Discussion Part Two This week's graded topics relate to the following Course Outcomes (COs). 1 Analyze pathophysiologic mechanisms associated with selected disease states. (PO 1) 2 Differentiate the epidemiology, etiology, developmental considerations, pathogenesis, and clinical and laboratory manifestations of specific disease processes. (PO 1) 3 Examine the way in which homeostatic, adaptive, and compensatory physiological mechanisms can be supported and/or altered through specific therapeutic interventions. (PO 1, 7) 4 Distinguish risk factors associated with selected disease states. (PO 1) 5 Describe outcomes of disruptive or alterations in specific physiologic processes. (PO 1) 6 Distinguish risk factors associated with selected disease states. (PO 1) 7 Explore age-specific and developmental alterations in physiologic and disease states. (PO 1, 4) Discussion Discussion Part Two (graded) Responses Lorna Durfee 6/5/2016 8:06:15 PM Discussion Part Two Johnny is a 5-year-old Asian boy who is brought to a family practice office with a “runny” nose that started about 1 week ago but has not resolved. He has been blowing his nose quite frequently and “sores” have developed around his nose. His mother states, “The sores started as ‘big blisters’ that rupture; sometimes, a scab forms with a crust that looks like “dried maple syrup” but continues to seep and drain.” She is worried because the lesions are now also on his forearm. Johnny’s past medical and family histories are normal. He has been febrile but is otherwise asymptomatic. The physical examination was unremarkable except for moderate, purulent rhinorrhea and 0.5- to 1-cm diameter weeping lesions around the nose and mouth and on the radial surface of the right forearm. There is no regional lymphadenopathy. Write a differential of at least five (5) possible diagnosis’s and explain how each may be a possible answer to the clinical presentation above. Remember, to list the differential in the order of most likely to less likely. Based upon what you have at the top of the differential how would you treat this patient? Differential diagnosis for this clinical presentation and justify it. When would you allow the student back to school? Elaborate on your reasoning. Doctor Brown: With my experience as a school nurse and physical trainer, I have seen many students come to the clinic with various complaints. However, I distinctly remember a particular student who exhibited the signs above and symptoms similar to these. Differential Diagnoses: #1 Impetigo #2 Molluscum Contagiosum #3 Rubella #4 Chicken pox #5 Hand, foot and mouth disease Differential Diagnoses: This patient exhibits the signs and symptoms of impetigo. He appears to have non-bullous impetigo. The blisters start as small vesicles and burst then have honey-colored serum. Yellow to white-brown or tan crust develops, and it looks like it is coated with honey or brown sugar. He has all the signs and symptoms that are part of the bacterial infection. McCance, Huether, and Brasher (2014) tell us that the crust is the identifying factor with a moist base that weeps when the scab is removed that identifies impetigo. The blisters can be on the face and the nose, but other areas such as the hands can be involved and extremities. There is no lymphadenitis (McCance et al., 2014, p. 1656). If we compare it to the differential diagnosis of the herpes simplex virus, we can see that HSV-1 is the type that induces oral infection (such as cold sores and fever blisters). However, there must be contact with saliva. With this infection, the virus affects cells of the epithelium and remains there in the dorsal root ganglion where it is latent. These lesions present with clusters and painful vesicles (on mouth, tongue and around the nose). Burning and paresthesias occur before onset. The vesicles rupture and form a crust. However, the lesions last for 2 to 6 weeks. Stress, light, fever and fatigue can cause reactivation (McCance, Huether & Brashers, 2014, p. 1636). The presentation and signs and symptoms of herpes do not coincide with the findings that we have with our current patient. Therefore, the differential diagnosis of Impetigo fits the presentation and the symptoms. #1 - Impetigo: Baddour (2016) has stated that Impetigo is a contagious bacterial infection observed more often in children. It has two distinct classifications, one of primary impetigo which is an invasion of the previously normal skin or direct bacterial invasion. The other classification is secondary impetigo which comes from skin trauma. This can include abrasions, minor trauma, and bites from insects. Eczema can also be an underlying condition. Impetigo is seen in children from two to five years old. It is not to say that adults and older children do not get the infection because they can. This infection is noted in warm and humid conditions and can spread easily through close contact. Carriage of group A Streptococcus and Staphylococcus aureus has been noted in patients with impetigo (Baddour, 2016). McCance, Huether, and Brashers (2014) explain that there are two types of impetigo; nonbullous and bullous. Both types start with vesicles with a thin vesicular roof that is formed from stratum corneum. Nonbullous is contagious, with superficial vesicles that are pustular and caused by Staphylococcus aureus or group A Streptococcus pyogenes. These microorganisms spread by direct contact with others who are infected or through insect bites. The lesions are smaller vesicles at first with honey-colored serum. There is a crust that forms as the vesicles rupture that is yellow to white-brown. There is lymphadenitis with nonbullous impetigo. Bullous impetigo is caused by Staph aureus. This organism is carried in the nose, perineal area and fingernails. It can be transmitted by an individual or with contaminated equipment. The bacterial toxins or exfoliative toxins cause disruption in the desmosomal adhesion molecules and form blisters. The blisters then coalesces to form bullae. There are lesions scattered over the skin. As these lesions rupture, they develop a honey-colored, flat crust that appears on the skin. The crust is the distinctive feature of impetigo. When the crust is removed, the skin base will be moist, inflamed and weeping. Lesions are found on the face, the nose, mouth and hands. It is possible that other areas of the body could develop lesions. There is usually no lymphadenitis (McCance et al., 2014, p. 1656). Treatment of Impetigo: Shim, Lanier, and Qui (2014) explain that The Infectious Diseases Society of America recommends topical mupirocin as first-line therapy, although known resistance to the drug exists. If the patient has numerous lesions and does not respond to topical treatment, then they should get treatment with oral antibiotics for S. pyogenes and S. aureus. The recommended antibiotics (oral) are dicloxacillin, amoxicillin/clavulanate, cephalexin. Also, the list includes erythromycin and clindamycin (Shim, Lanier, & Qui, 2014, p. 335). McCance et al., (2014) tell us that antibiotic therapy should be determined by bacterial culture and drug sensitivity because the prevalence of impetigo in the community is increasing. Methicillin-resistant S. aureus and impetigo are increasing. For more extensive impetigo systemic antibiotics may be needed. However, beta-lactam antibiotics should be avoided if MRSA is suspected (McCance et al., 2014, p. 1656). When will the child be allowed back in school? The patient should remain out of school initially for 24 hours after starting antibiotics. If the lesions are still weepy, oozing and wet, they should be covered. Washing hands with soap can reduce the incidence of impetigo. Schools may have policies that vary when it comes to the amount of time to remain out of school after the 24 hour period (Dynamed, 2015). Additional care includes covering the lesions with a watertight dressing. Also, make sure to wash all clothes, towels, and bedding with hot water and keep separate. #2 - Molluscum contagiosum: Molluscum contagiosum is a poxvirus that causes a localized infection with small papules on the skin. It is not as fatal as smallpox. However, it is similar to that virus. The only know host for Molluscum contagiosum is humans. Like the vaccinia and variola viruses molluscum replicates in the cytoplasm of the cells. The human genome study revealed that more than one-half of the genes are similar to those in variola and vaccinia viruses. Because the diseases are different, there are also many genes found in variola and vaccinia that are not found in the genome for molluscum contagiosum. Molluscum has unique genes that encode proteins for host defense mechanisms. These inhibit the host inflammatory response and response to the infection (Isaacs, 2016). There are four genotypes, but genotype 1 represents 90 percent of cases in the United States. There is also an indication that mild cases that are subclinical may be more prevalent in the community (Isaacs, 2016). McCance, Huether, and Brashers (2014) explain that the aformentioned virus will induce cell proliferation that blocks responses that would control the virus. The epidermis grows into the dermis and forms saccules that contain virus clusters. The cell is composed of mature, immature and incomplete viruses and debris. The lesions are dome-shaped and can appear on the face, trunk, and extremities. They are usually quite quiet unless they are traumatized, or there is a secondary infection (McCance et al., 2014, p. 1658). This condition does not fit our patient’s symptomatology and presentation. #3 - Rubella (German Measles): Rubella is a communicable disease of children caused by a ribonucleic acid (RNA) virus that enters into the system through the respiratory route. It is a mild disease, and incubation is from 14 to 21 days. There are enlarged lymph nodes, fever (low-grade), sore throat and runny nose with a cough. There is a faint pink to red rash that is maculopapular. This rash can develop on the face and then trunk and extremities. The rash is not seen on the palms or soles of the feet. The virus causes dissemination of the skin. Children are not contagious after the development of the rash. There is lifelong immunity to rubella, along with measles, chickenpox, and roseola if you contact the disease (McCance et al., 2014, p. 1658). The rash presentation is not the same as the patient’s presentation. #4 - Varicella (chickenpox): Varicella is a disease that is seen in childhood and approximately 90 percent of children develop the disease during their first decade in life. This virus is very contagious and spreads from person-to-person via airborne droplets. With infection in the household, there is a 90 percent chance that people who are susceptible will get the disease within 14 days. Children remain contagious for one day before the rash develops. Transmission can happen up to 5 to 6 days after onset of lesions in healthy children. There are no prodromal signs (McCance et al., 2014, p. 1660). The illness may appear with vesicles on the trunk, scalp, and face. Later on, it spreads to the extremities. The lesions have various stages. They can present as macules, papules, and vesicles. They rupture easily. They develop a crust. Sometimes they can be found in the mouth, conjunctiva, and pharynx. There is a fever for 2 to 3 days (McCance et al., 2014, p. 1660). This disease fits some of the signs and symptoms but not all. The presentation is different. #5 - Hand, foot, and mouth disease: The Centers for Disease and Control and Prevention (2015) explain that hand, foot and mouth disease is a common viral illness that affects children younger than 5. It does, however, occur in adults. It usually starts with a fever, lack of appetite and sore throat and just not feeling well. Once the fever starts, about two days later, painful sores develop in the mouth. A skin rash with red spots develops that blister. The blisters can appear on the palms, hand, feet (soles) or the elbow, knees or buttocks. Some people do not show signs, but they still pass the virus to others. The viruses that belong to the Enterovirus genus (polioviruses, coxsackieviruses, and echoviruses and enteroviruses. Coxsackievirus A16 is the most common in the United States, but other viruses that are enterovirus can cause illness. Enterovirus 17 has been associated with the disease as well. Transmission can occur through close contact, in the air with coughing and objects contaminated with feces and contaminated surfaces and objects (The Centers for Disease Control and Prevention, 2015). Although this is a differential, it does not appear to fit the case presented. References Baddour, L. M. (2016). In T.W. Post (Ed.) UpToDate. Impetigo. Retrieved from Dynamed (2015, Aug 17). Impetigo. Ipswich (MA): EBSCO Information Services. Retrieved June 5, 2016, from Isaacs, S. N. (2016). In T.W. Post (Ed.) UpToDate. Molluscum contagiosum. Retrieved from McCann, S. A. (2014). Structure, Function, and Disorders of the Integument. In McCance, K. L., Huether, S. E., Brashers, V. L (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., p. 1636). St. Louis, MO: Mosby. Nicole, N. H. (2014). Alterations of the Integument in Children. In McCance, K. L., Huether, S. E., Brashers, V. L. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., pp. 1656, 1658, 1660). St. Louis, MO: Mosby. Shim, J., Lanier, J., & Qui, M. K. (2014). Clinical inquiry: what is the best treatment for impetigo ?. The Journal Of Family Practice, 63(6), 333-335. The Centers for Disease Control and Prevention. (2015). Hand Foot and Mouth Disease. Retrieved from Rechel DelAntar reply to Lorna Durfee 6/7/2016 7:11:20 PM RE: Discussion Part Two Hello Lorna, I too have came up with the conclusion of Impetigo but I have not considered hand, foot and mouth disease as a diagnosis and have learned much from your post. The symptoms are similar to that of our case study. Hand-foot-and-mouth disease is an illness that causes sores in or on the mouth and on the hands, feet, and sometimes the buttocks and legs. The rashes is similar in location and is very common among children because kids have a tendency to put their hand on their mouth all the time and fever prior to the rashes appearing however, in hand, foot and mouth disease, the rashes are painful and the appearance is more reddish and flat (Centers for Disease Control and Prevention, 2015). This is a good differential diagnosis to consider. Reference: Centers for Disease Control and Prevention. (2015). Hand, foot and mouth disease. Retrieved from Alice Jeffries reply to Rechel DelAntar 6/11/2016 6:44:18 PM RE: Discussion Part Two Lorna, It is so nice to have someone in the class who has worked with children, and no tin a hospital setting! It is a completely different kind of health care and probably more similar to what we will see in a clinical setting. Ali Joleen Jimenez reply to Lorna Durfee 6/13/2016 6:16:42 AM RE: Discussion Part Two I, also, had not considered hand, foot, and mouth disease to be a differential diagnosis. After considering the clinical manifestations and reading more about this virus, it should have been considered. To add to the information formerly presented, this viral infection is caused by the human enterovirus from oral ingestion from the gastrointestinal tract or upper respiratory tract of an infected individual. It is important to consider that the virus can be detected in the stool for six weeks up to seven months after infection and in the oropharynx for up to four weeks. Therefore, continued hand hygiene is essential to prevent further exposure. The incubation period for this disease is usually three to five days. Another consideration for this virus are the possible complications, which surprisingly, although rare, can be severe. The complications include: decreased oral intake, rhombencephalitis, acute flaccid paralysis, aseptic meningitis, myocarditis, fetal loss, and conjunctival ulceration (Romero, 2015). The take away for this virus, is hand hygiene, hand hygiene, and hand hygiene!! Education of patients and families is essential to prevent further spread. Joleen Reference: Romero, J. (2015). Hand, foot, mouth disease and herpangina: an overview. UptoDate. Retrieved from source=search_result&search=hand+foot+and+mouth+disease&selectedTitle=1%7E21 Sarah Boulware 6/6/2016 3:34:34 PM Part Two Dr. Brown and Class, 1. Non- bullous Impetigo secondary to a Rhinitis. Impetigo is a highly contagious superficial bacterial skin infection that is transmitted by direct contact. Primary impetigo occurs when there is a direct bacterial invasion of minor breaks in normal skin. Secondary impetigo occurs when the infection is secondary to an underlying skin disease or as a result of trauma or skin burns. Impetigo can be non-bullous or bullous. Non-bullous is the most common. Bullous impetigo is characterized by blisters or bullae and occurs as a result of a Staphylococcus aureus. Impetigo is frequently seen in children with an average yearly incidence of 2.8 percent. Impetigo occurs when bacteria access a break in the skin, such as a cut or dry, cracked skin. This results in symptoms of boils, abscesses, and pus-filled lumps on the skins surface that are painful. This leads to a crust on the skin (impetigo), redness, swelling, and pain in the underlying tissues, also known as cellulitis. If not treated the infection can advance and become more severe (Lawton, 2015). The non-bullous impetigo vesicles are small fluid-filled blisters or pustules that commonly occur around the mouth and nose. The lesions rapidly burst and develop into gold-crusted plaques that are typically 2cm in diameter. Satellite lesions may occur as a result of autoinoculation. Bullous impetigo is characterized by flaccid fluid-filled vesicles and blisters that are between 1 to 2 cm in diameter in size. When they rupture they leave the skin raw and form a thin flat brown to golden crust. These lesions spread rapidly and are painful. Systemic symptoms such as weakness, fever, diarrhea, and lymphadenopathy may be present. It is less common in the face and often develops around the axilla and neck folds (Lawton, 2015). Johnny’s symptoms match the description for non-bullous impetigo. The lesions on his arm are likely satellite lesions. This infection likely occurred due to a break in the skin around the nose from rhinitis and constant nose blowing. Localized non-bullous impetigo should be treated with topical fusidic acid three to four times a day for seven days. The crusts of the plaques should be removed by soaking them in soapy water before application. Removal of the crust allows the medication to come into direct contact with the bacteria. Topical antibiotics are not recommended as the first choice of treatment. If the impetigo is bullous, extensive, or severe with systemic symptoms, oral antibiotics are indicated for treatment. Oral antibiotics need to be prescribed according to the bacteria and adjusted if the bacteria are resistant to antibiotics. Since impetigo is a highly contagious superficial infection, Johnny should not be allowed to return to school until his lesions have healed. Johnny is a five-year old and his constantly blowing his nose, increasing the risk of transmission through contact by constantly having his hands around the lesions and likely not performing proper hand hygiene (Lawton, 2015). 2.Herpes Simplex Virus (HSV) Type 1 HSV type 1 is a type of the HSV that results in an outbreak of small blisters or sores on or around the mouth. The sores typically heal within two to three weeks but the virus will remain and periodically flare up. Impetigo sores and HSV type 1 sores can closely resemble each other; therefore it is essential to differentiate impetigo sores from HSV type 1 sores by obtaining a culture. It also spreads through direct contact. Blisters develop around the nose or mouth and become itchy and painful (U.S. National Library of Medicine, 2016). 3. Atopic Dermatitis Atopic dermatitis occurs from a skin reaction or allergy. People with atopic dermatitis often have asthma and seasonal allergies. Skin changes may include blisters with oozing and crusting. Johnny is exhibiting this symptom and his runny nose may be due to seasonal allergies. Other symptoms associated with atopic dermatitis include dry skin all over the body, ear discharge or bleedings, skin color changes, and skin redness or inflammation. Johnny is not exhibiting any of these symptoms and his sores are localized around his nose. In children older than two years of age dermatitis usually presents itself as a rash that is commonly seen on the inside of the knees and elbows. Intense itching is often the main symptom. Johnny is not experiencing any of these symptoms (U.S. National Library of Medicine, 2014). 4. Stevens-Johnson Syndrome (SJS) SJS begins with a fever and flu-like symptoms. Within a few days the skin begins to blister and peel, forming very painful raw areas called erosions that resemble a severe hot water burn. The skin erosions typically start on the face and chest before they spread to other areas of the body. This can be a life threatening condition due to severe damage to the skin and mucous membranes. Johnny has had a fever and runny nose but his sores resemble impetigo rather than SJS (National Institute of Health [NIH], 2016). 5. Pemphigus vulgaris Pemphigus is an autoimmune skin disease. It leads to deep blisters that do not break easily. The immune system attacks healthy cells in your skin and mouth, which causes blisters and sores. It does not spread from person to person. Johnny’s sores break open and drain easily and pemphigus is not usually diagnosed in children (U.S. National Library of Medicine, 2015). References Lawton, S. (2015). Identifying common skin infections and infestations. Journal of Community Nursing, 29(1), 41-47. National Institute of health. (2016). Stevens-Johnson Syndrome. Retrieved from U.S. National Library of Medicine. (2014). Atopic Dermatitis. Retrieved from U.S. National Library of Medicine. (2015). Pemphigus. Retrieved from U.S. National Library of Medicine. (2016). Herpes Simplex. Retrieved from Lanre Abawonse 6/7/2016 5:01:17 PM Discussion Part Two Write a differential of at least five (5) possible diagnosis’s and explain how each may be a possible answer to the clinical presentation above. Remember, to list the differential in the order of most likely to less likely. Nonbullous Impetigo is one of the most common bacterial infections that is acute in nature and is found mostly in children. This acute disease is a very contagious skin disease characterized by the formation of vesicles, pustules, and yellowish crust. Bullous impetigo is caused by S.aureus and is characterized by large, flaccid bullae (HartmanAdams, Banvard, & Juckett, 2014). The staphylococci or streptococci is said to occur in approximately 5% of the population each year and about 60% population of this disease are carriers. With the patient in question this seems to be appropriate diagnosis. Herpes Simplex Virus Herpes simplex virus is a common infection of the skin and mucous membranes. There is type 1 and type 2 of the human herpesvirus, with HVS 1 affecting the above the waste areas and sometimes occurs as a result of spread of other infections. HSV 2 is responsible for most infections in the genital areas. Lesions most likely begin a with burning or tingling sensation. The vesicles and erythema is followed by pustules, ulceration and crust. Many reside around the lips, face, and mouth. Pain is common, Painful blisters that appear like pimples eventually crust over and scab (Newton, 2013). Molluscum Contagiosum Molluscum Contagiosum is a viral skin disease caused by the pox virus family. They cause eruption on the skin. At the point of invasion of the epidermis, this virus presents as pink to white lesions. These lesions are sometime multiple, are slow to develop, and tend to remain stable for long time. The manifestations are much more mild than those of chickenpox or smallpox. This is a self-healing disease and treatment in not recommended, especially in children (Sharquie, Hameed, & Abdulwahhab, 2015). Atopic dermatitis Atopic dermatitis (AD) is often refered to as a type of pruritic eczema that usually begins during infancy and is mostly associated with allergy with a hereditary tendency. The AD appears in children with lower threshold for cutaneous itching, and tends to appears as a result of scratching from the intense pruritus. Repeated scratching makes the condition worse. Vesicles start to appear, they get infected and pustules, weeping, crusting and cellulitis can develop (Watkins, 2015). Rubella Rubella is a viral infection caused by a rubivirus that occurs in childhood. It is also known as 3 day measles and German measles. A diffuse punctate, macular rash begins on the trunk and spreads to the arms and legs. The child might also present with cold like symptoms (cough). The virus might be present in blood, stool, and urine. Patients might have a headache, malaise and lymphadenopathy. Patients may present with not feeling well with a low grade fever (temperature less than 100F), sore throat and coryza (Watkin, 2014). Based upon what you have at the top of the differential how would you treat this patient? To treat impetigo, a proper topical application must be used. One can begin the treatment by using 2% mupirocin ointment (bactroban) or the use of 1% retapamulin ointment. If Johnny is febrile and large areas are involved, I would add an oral antibiotic to managed impetigo systemically with the use of dicloxacillin, cephalexin or erythromycin and Augmentin (Hartman-Adams, Banvard, & Juckett, 2014). When would you allow the student back to school? Elaborate on your reasoning? Due to the nature of the disease process and the transmission, it is better to prevent the spread of the infection to others. It appears that Johnny is highly contagious. Therefore, Johnny can return to school 72 hours after he has started the oral antibiotics as long as there is no more oozing or discharge and the sore is scabbed over (Estes, 2015). Reference Estes, K. R. (2015). Skin infections in high school wrestlers: A nurse practitioner's guide to diagnosis, treatment, and return to participation. Journal of the American Association of Nurse Practitioners, 27(1), 4-10. doi:10.1002/.12136 Hartman-Adams, H., Banvard, C., & Juckett, G. (2014). Impetigo: diagnosis and treatment. American Family Physician, 90(4), 229-235. McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby. Newton, H. (2013). Viral infections of the skin: clinical features and treatment options. Nursing Standard, 27(52), 43- 47 5p. Sharquie, K. E., Hameed, A. F., & Abdulwahhab, W. S. (2015). Pathogenesis of Molluscum Contagiosum: A new concept for the spontaneous involution of the disease. Our Dermatology Online / Nasza Dermatologia Online, 6(3), 265-269. doi:10.7241/ourd.20153.72 Watkins, J. (2014). Rubella: An overview of the symptoms and complications. British Journal of School Nursing, 9(6), 284-286 3p. Watkins, J. (2015). Common causes of itching in children. Practice Nursing, 26(7), p. Instructor Brown reply to Lanre Abawonse 6/8/2016 4:00:03 PM RE: Discussion Part Two What patho process is going on with "vesicles and erythema is followed by pustules, ulceration and crust"? Lanre Abawonse reply to Instructor Brown 6/10/2016 10:05:44 AM RE: Discussion Part Two Dentinogenesis imperfecta (DI) has been reported in more than 50% of patients suffering from osteogenesis imperfecta OI. DI is a hereditary disorder of dentin formation, which exhibits mostly an autosomal dominant (AD) trait. It’s the part of the process that affects DI. Biria, Abbas, Mozaffar, and Ahmadi (2012) stated that DI type I is the oral manifestation of deficient collagen formation and is mainly associated with OI. Primary and permanent dentitions are both involved in DI type I, though primary teeth are more severely affected. As a result of this, the most common clinical manifestations in teeth with DI are teeth discoloration (gray/opalescent, yellow/brown) and enamel fracture. Reference. Biria, M., Abbas, F. M., Mozaffar, S., & Ahmadi, R. (2012). Dentinogenesis imperfecta associated with osteogenesis imperfecta. Dental Research Journal, 9(4), 489–494. Lanre Abawonse reply to Lanre Abawonse 6/10/2016 10:08:32 AM RE: Discussion Part Two Please disregard the answer, thanks Nosimot Adepegba reply to Lanre Abawonse 6/13/2016 10:23:06 PM RE: Discussion Part Two Hello Lanre. I enjoyed reading your informative post. I would like add to your points on the Molluscum Contagiosum (MC). Although MC is considered a mild skin disease it is important to educate and prevent the spread of it even though the mode of its transmission is conflicting. It is believed that it could be transmitted through sharing personal items like towels, clothes, cup and cutleries. Sexual contact with an infected person may activate a spread. MC is a topical infection that does not pass into the blood circulation therefore may not be contacted through droplets (CDC, 2015). Great post. Centers for Disease Control and Prevention [CDC]. (2015). Molluscum Contagiosum. Retrieved from Rechel DelAntar 6/7/2016 6:49:46 PM Differential Diagnosis Hello Professor and Class, Differential Diagnoses This is a case of a 5 year old boy who is brought to the office with symptoms of “runny” nose that started a week prior. Patient has developed “sores” in his nose from frequent blowing of his nose. Mother reports that lesions are now progressing to his forearms and they start out as big blister that rupture and appears to be like “dried maple syrup” that continues to drain. Through this all, the mother has not reported any incidence of pain experienced from these blisters. The lesions are present in the child’s nose, mouth and radial surface of forearms. No significant patient and family history noted. Based on this assessment, the child may be having: 1. Impetigo = is a contagious bacterial infection most common among preschool children but can occur at any age. This is caused by Staphylococcus Aureus or Group A Streptococcus. Incubation period is between 4-10 days for Staph. Aureus and 1-3 days for Streptococcus. Among adults, it is common among people who play contact sports. There are 3 different types of Impetigo; Contagious Impetigo, the most common and is painless causing blisters in mouth and nose and leaves a “honey” colored scab which will eventually heal without scabbing and no lymphadenopathy; Bullous Impetigo occurring mostly among children 2 and below which shows painless blisters in trunk and arms with no enlargement of the lymph nodes and Ecthyma which is characterized by pain pus or fluid like blisters which may leave scabs and produce swollen lymph nodes (Tamparo, C. and Lewis, M. (2011). Based on the symptoms described by the mother, the child may be having contagious Impetigo which may have been acquired from close contact with other preschool students in class. 2. Eczema = Otherwise known as Atopic Dermatitis. Atopic describes the over sensitivity to allergens in the environment. Eczema is a skin condition caused by inflammation of the skin. Typically, eczema causes skin to become itchy, red, and dry -- even cracked and leathery. Eczema can appear on any part of the body. Many people have it on their elbows or behind their knees. Babies often have eczema on the face, especially the cheeks and chin. They can also have it on the scalp, trunk (chest and back), and outer arms and legs and children and adults tend to have eczema on the neck, wrists, and ankles, and in areas that bend, like the inner elbow and knee. People with eczema are usually diagnosed with it when they are babies or young children and at times have runny nose and hay fever like symptoms prior to the rashes. It is not an allergy in itself but allergies may trigger it (Kids Health, 2016). Although, some of the symptoms are similar to the patient, rashes in eczema appear to be spread and not specific to a certain area. Also the rashes in eczema are not blister like and does not crust over which is what the patient is experiencing. 3. Chickenpox (Varicella) = Chickenpox is a very contagious disease caused by the varicella-zoster virus (VZV) that blister like rashes, itching tiredness and fever. The classic symptom of chickenpox are rashes that turn into an itchy and blister filled that eventually scabs. Rashes appear from the chest and trunk and spreads through out the body. Symptoms such as fever and tiredness appear 1-2 days prior to the rashes and lasts for 5-7 days (Centers for Disease Control, 2016). Although this disease is characterized by rashes, it does not fit the description of the rashes experienced by child. The child’s rashes are also very specific to the mouth, nares and forearms while chickenpox rashes are spread all over the body. 4. Measles = This is a highly contagious infection caused by the measles virus. Classic signs of measles are the 4 days of fever (4Ds) and three C’s – cough, coryza and conjunctivitis prior to the appearance of rashes. Fevers are typically high at 104F and the rashes are described as a generalized red maculopapular rash that begins several days after the fever starts. It starts on the back of the ears and, after a few hours, spreads to the head and neck before spreading to cover most of the body, often causing itching and appears two to four days after the initial symptoms and lasts for up to eight days (Beisbroeck, L. and Sidbury, R., 2013). Although this is a disease characterized by rashes, they do not fit the description of the patient. Further more, the patient may have some runny nose but he is not experiencing any cough, conjunctivitis and high temperatures. 5. Dermatophytosis = Otherwise known as ringworm is a fungal infection of the skin. Anyone can develop ringworm. However, the infection is very common among children. collectively dermatophytes, feed on keratin, the material found in the outer layer of skin, hair, and nails. These fungi thrive on warm and moist skin, but may also survive directly on the outsides of hair shafts or in their interiors. It can occur in different areas of the body and is characterized with red, scaly, itchy or raised patches. Patches may be redder on outside edges or resemble a ring (Mayo Clinic, 2016). This would not fir the patient because the rashes in ringworm are more scaly than blister like. Also ringworm appears all over the body and not specific to the mouth and nares area. Treatment for Impetigo is the administration of topical or oral antibiotics. Mild cases can be treated by bactericidal ointment such as Mupirocin. However, severe cases may be treated with oral antibiotics such as Doxycycline, erythromycin or amoxicillin. Continue medical treatment until all sores are healed. Your child can go back to school, kindergarten or day care after 1 week if topical antibiotics are started and 24 hours to 48 hours after oral antibiotics are started. Small children will touch and scratch their scabs and therefore run the risk of infecting other children. By waiting until the bacteria is no longer contagious, it prevents the spread of the disease to other children (Indiana State Department of Health, 2014). References: Beisbroeck, L. and Sidbury, R. (2013). Viral exanthems: An update. Dermatologic Therapy. 26(6), 433-438. Centers for Disease Control. (2016). Chickenpox. Retrieved from Indiana State Department of Health. (2014). Impetigo. Retrieved from Kids Health. (2016). Eczema. Retrieved from Mayo Clinic (2016). Ringworm (Body). Retrieved from diseases-conditions/ringworm/basics/definition/con-. Tamparo, C. and Lewis, M. (2011). Diseases of the Human Body. Philadelphia, PA:F.A. Davis Company. Instructor Brown reply to Rechel DelAntar 6/8/2016 3:58:44 PM RE: Differential Diagnosis Will the s/s be the same for staph and strep? If so, why? If not, why? Rechel DelAntar reply to Instructor Brown 6/8/2016 9:46:11 PM RE: Differential Diagnosis Hello Professor and Class, Streptococcus vs. Staphylococcus in Impetigo Impetigo is most commonly seen in children from 2-5 years old and classifies as bullous and nonbullous. The skin infection is caused by Group A streptococcus (GAS) or Staphylococcus aureus. Impetigo related to Streptococcus has relatively mild symptoms the nonbullous type of impetigo, which lasts for 1-3 days. This is because dried Streptococci in the air are not infectious to intact skin. Impetigo from Staphylococcus Aures is associated with the bullous type. For the most part, it produces smaller bullae and develops into the honey crusted lesions. This is due to the toxins released by the organism producing intradermal cleavage. More severe or widespread impetigo, especially of bullous impetigo, may require oral antibiotic medication. In recent years, more staph germs have developed resistance to standard antibiotics. If clinical suspicion supported by culture results show other bacteria, such as drug-resistant staph (methicillin-resistant Staphylococcus aureus or MRSA), other antibiotics may be necessary (Department of Health NY State, 2011). Reference: Department of Health NY State. (2011). Bacterial Infections: Impetigo and MRSA. Retrieved from athletic_skin_infections/. Liberty Neoh 6/7/2016 10:01:40 PM Discussion Part Two Dr. Brown and Class, Write a differential of at least five (5) possible diagnosis’s and explain how each may be a possible answer to the clinical presentation above. Remember, to list the differential in the order of most likely to less likely. Bullous Impetigo is a common bacterial skin infection that affects children, particularly, children aged two to five years. Staphylococcus Aureus is the most common organisms causing bullous impetigo. Bullous impetigo starts with smaller vesicles, which become flaccid blisters, measuring up to 2 cm in diameter, initially with clear content that later becomes purulent. Bullous impetigo occurs most commonly in diaper area, axillae and neck, although any cutaneous area can be affected, including palms and soles. Regional enlarged lymph nodes are usually absent (Pereira, 2014). Chicken pox is caused by Varicella Zoster Virus, a common childhood illness that is usually mild. Chickenpox begins with a fever, followed in a day or two by a rash that can be very itchy. The rash starts with red spots that soon turn into fluid-filled blisters. Rash usually appears first on the head, chest, and back then spreads to the rest of the body. The lesions are usually most concentrated on the chest and back. Some people have only a few blisters while others can have numerous. These blisters usually dry up and form scabs in 4 or 5 days (Centers for Disease Control, 2016). Johnny’s blisters first appeared around his nose. He did have a fever according to his mother. The rash distribution does not seem to fit the description of chicken pox. Herpes Simplex Virus (HSV) can cause both mucocutaneous and systemic disease, and both HSV-1 and HSV-2 can cause the same syndromes. The most severely affected are neonates, who usually acquire the disease during birth through exposure to infected genital secretions. In general populations, HSV infections are confined to skin and mucosa. People who are immunocompromised, such as HIV patients, these symptoms can be severe (Pinheiro et al, 2013). Staphylococcal scalded skin syndrome (SSSS) is a potentially life-threatening disorder caused most often by a phage group II Staphylococcus aureus infection. Staphylococcal scalded skin syndrome is more common in newborns than in adults. Clinical signs are sudden with diffuse erythema and fever. Certain strains of Staphylococcus aureus release serine protease which causes destruction of cell–cell adhesion and creating blistering and exposing the skin (Handler & Schwartz, 2014) Steven Johnson’s syndrome (SJS) is a rare but life-threatening condition. The most common clinical characteristics of SJS are mucocutaneous eruption at early stage and contributes to the high mortality rate. SJS was first described in 1922 by two American physicians named Stevens and Johnson. An acute mucocutaneous syndrome in two young boys in their research was characterized by severe purulent conjunctivitis, severe stomatitis with extensive mucosal necrosis. The most frequent cause of these conditions is medication (Naveen et al, 2013). Based upon what you have at the top of the differential how would you treat this patient? According to Hartman-Adams and her colleagues (2014), treatment options for impetigo may include topical antibiotics, systemic antibiotics, and topical disinfectants”. They further stated that here was no clear evidence as to which intervention is most effective. Topical antibiotics are more effective than placebo and preferable to oral antibiotics for limited impetigo. Systemic antibiotics are often reserved for more generalized or severe infections in which topical therapy is not practical. Clinicians may sometimes choose both topical and systemic therapy and have to consider the effective ness, side effects, and costs of treatments. When would you allow the student back to school? Elaborate on your reasoning? An article by Estes (2015) suggested that “impetigo is “noncontagious” when all lesions are scabbed over and dry. There should no longer be any oozing or discharge and for at least 48 h there should be no new lesions present. Antibiot