PART 1: Complete the following differential diagnoses tables.

All students must complete the following differential diagnoses tables. An exemplary example is
provided in the first row of each of the three tables.

Table 1. Dermatologic Differential of Common Skin Lesions and Rashes

Name Cause Signs/Symptoms Diagnostics Treatment

Rocky Mountain Tick Fever, chills, severe Antibody titers to Doxycycline 100mg
Spotted Fever bite Rickettsia headache, n/v, photophobia, rickettsia for 7-14 days – can b
rickettsii myalgia, conjunctival Punch biopsy if not started on treat
injection, arthralgia; 2-5 days CBC, LFT, CSF within 8 days. Remo
after onset - rash (petechiae) by grasping closest t
starts on hands/feet to trunk and apply steady upw
(palmar rash) pressure

Bite from
infected
Expanding circular red rash
Erythema Migrans Ixodes tick Antibody tests for Antibiotics (Amoxic
(bull's eye), fatigue, fever,
(Lyme Disease) (Borrelia Borrelia burgdorferi Doxycycline) for 2-4
headache, muscle/joint aches
burgdorferi
bacteria)

Sudden high fever, severe Emergency medical

Neisseria headache, stiff neck, attention
Blood tests, bacterial
Meningococcemia meningitidis nausea/vomiting, confusion, required. Antibiotics
cultures
bacteria rash (may appear like intravenous fluids,
bruises), lethargy respiratory support.

Chickenpox (blistering rash,

Varicella- fever, fatigue) or Shingles Visual diagnosis, Antiviral medication
Varicella/Zoster
zoster virus (localized blistering rash with PCR test (Acyclovir, Valacycl
sharp neuralgia pain)

Malignant Melanoma Uncontrolled Dark, irregular mole with Biopsy Surgery, radiation,
growth of skin color variation, blurred chemotherapy,
 pigment cells borders, size/shape change immunotherapy

Uncontrolled Slow-growing pearly or

Basal Cell Surgery, Mohs surge
growth of waxy bump, often with Biopsy
Carcinoma cryotherapy, radiatio
basal skin cells visible blood vessels

Precancerous
Topical medications
rough, scaly
Actinic Keratosis Skin biopsy (fluorouracil, imiquim
patches caused
cryotherapy
by sun damage

Requires immediate
Severe allergic Painful, blistering rash on
Erythema medical
reaction to mucous membranes (mouth, Skin biopsy, allergy
Multiforme (Stevens- attention. Supportive
medications or eyes, genitals) and skin, testing
Johnson Syndrome) medications to mana
infections fever, malaise
symptoms.

Table 2. Differential Diagnoses of Eye Emergencies

Name Cause Signs/Symptoms Diagnostics Treatment

Corneal Abrasion Trauma, Acute onset severe eye Eye exam with Flush eye with sterile normal sa
foreign body, pain with tearing. Fluorescein Evert eyelid to look for foreign
incorrect use of Reports feeling of dye Topical antibiotic trimethoprim
contact lenses foreign body sensation polymyxin B
(Polytrim),Ciprofloxacin (Cilox
Ofloxacin (Ocuflox) to affected
3-5 days.
Do not patch eye.

Hordeolum (Stye) Bacterial Small, red, tender bump Visual Warm compresses, lid scrubs, t
infection of an on the eyelid margin diagnosis antibiotics. In severe cases, inci
oil gland near and drainage may be needed.
the eyelash
 base

Blockage of an Painless bump on the Warm compresses, lid scrubs.

Visual
Chalazion oil gland inside eyelid, may be tender to Injection of steroids or surgical
diagnosis
the eyelid touch removal in persistent cases.

Localized,
yellowish
thickening of
the conjunctiva
- Usually requires no treatment
(white part of Small, raised, yellowish Visual
Pinguecula Surgical removal for cosmetic
the eye) near bump, usually painless diagnosis
reasons.
the cornea,
usually caused
by sun
exposure

Overgrowth of
the conjunctiva Triangular-shaped
onto the fleshy growth on the
- Lubricating eye drops. - Surgi
cornea, often white of the eye, may
Pterygium Eye exam removal in severe cases affectin
linked to extend towards the
vision.
chronic sun cornea, causing blurred
exposure and vision
irritation

Broken blood
vessel beneath
the
Sudden appearance of a - Usually resolves on its own w
Subconjunctival conjunctiva, Visual
bright red patch in the 1-2 weeks. - Cold compresses i
Hemorrhage causing a red diagnosis
eye, usually painless first 24 hours.
patch on the
white of the
eye
 Damage to the
optic nerve due
Early stages often have
to increased
no symptoms. In later
pressure in the Eye exam, - Eye drops to lower eye pressu
Primary Open-Angle stages: gradual vision
eye, often pressure test, Laser surgery or traditional surg
Glaucoma loss, peripheral vision
related to visual field test in some cases.
loss, tunnel vision, eye
blocked fluid
pain (rare).
drainage
channels

Age-related
deterioration of
the macula Blurred central vision, - No cure, but treatments like
Eye exam,
(central area of difficulty seeing colors, injections and nutritional
Macular Degeneration special
the retina distorted vision (straight supplements may help slow
imaging tests
responsible for lines appearing wavy) progression.
sharp central
vision)

Table 3. Differential Diagnoses of Common Headaches

Aggravating
Name Signs/Symptoms Acute Treatment
Factors

Migraine Without Throbbing pain behind one Red wine, MSG, Ice pack on forehead, rest in dark quiet
Aura eye, photophobia, N/V aspartame, room
phonophobia, last 4-72 hr. menstruation, Triptans, Tigan suppositorie
stress

Migraine With Aura In addition to migraine Same as migraine Same as migraine without aura
without aura without aura
symptoms: Visual
disturbances (flashing lights,
 blind spots) before the
headache

Severe, stabbing facial pain, Touching

Trigeminal Neuralgia usually one-sided, lasting specific facial - Anticonvulsant medications (e.g.,
(CN V) seconds to minutes, triggered trigger zones, Carbamazepine).
by specific touch points chewing, talking

Severe, burning or piercing

pain, usually behind one eye, Alcohol,
lasting 15 minutes to 3 hours, smoking, sudden - High-flow oxygen therapy. - Inhaled
Cluster Headache
occurring in clusters (several changes in sumatriptan.
attacks per day for temperature
weeks/months)

Dull, aching pain on both

Stress, muscle - Over-the-counter pain relievers
Muscle Tension sides of the head, often
fatigue, poor (acetaminophen, ibuprofen). - Relaxatio
Headache described as a tight band
posture techniques (massage, heat therapy).
around the head

PART 2: Case Study

Case Study

1. Sally is a 22-year-old female who recently became bothered by a rash that is itchy, red,
inflamed, and dry. She also has scaly areas that she says are getting worse. The rash is
only around her umbilicus and on her elbows. Both of her parents have psoriasis, but she
doesn't believe this is the problem, because it appears to be different from her parents'
lesions. She is living in Florida, is under a lot of stress in high school, and just recovered
from a lingering upper respiratory infection (URI).

If you chose case study 1 or 2, complete the below Differentials Table

Differential Signs/Symptoms Gold Standard Gold Standard Treatment
 Diagnostics

Ex: Actinic Scaling, dry,

Clinical diagnosis For patients with multiple thin lesions on the fac
Keratosis round, flesh-
topical fluorouracil cream is first-line therapy.
colored lesions
Applied to AK lesions, fluorouracil cream cause
on skin that do
necrosis. Inflammation typically subsides appro
not heal; usually
topical fluorouracil is discontinued. It typically
sunexposed
to four weeks of which are active treatment) for
areas; sizes range
erythema, blistering, necrosis with erosion, and
from microscopic
patients with extensive AK, the treated area may
to several
inflamed. Thus, pretreatment patient informatio
centimeters.
thorough to ensure adherence to treatment.

Inflammatory response during treatment of AK

Itchy, red,
inflamed, and dry
rash with scaly Clinical diagnosis, skin Topical corticosteroids, moisturizers, photothera
1.Psoriasis
areas; typically biopsy for severe cases.
on elbows, knees,
and scalp.

Red, itchy rash

occurring after
contact with
2.Contact
irritant or Patch testing Avoidance of allergen, topical corticosteroids, a
Dermatitis
allergen; may
have vesicles or
oozing.

3.Fungal Red, inflamed Microscopic examination Antifungal creams or oral antifungal medication
Infection rash with scaling of skin scrapings clean and dry.
and itching; may
 have satellite
lesions.

Yellowish,
greasy scales on
4.Seborrheic scalp, face, or Clinical diagnosis, Antifungal shampoos, corticosteroid creams, me
Dermatitis other body areas; sometimes skin biopsy zinc pyrithione or tar.
itching and
redness.

Dry, itchy,
inflamed skin
5. Atopic with eczematous Emollients, topical corticosteroids, antihistamin
Clinical diagnosis
Dermatitis patches; phototherapy in severe cases.
commonly found
in flexural areas.

Review of Systems (ROS)

 General: Have you experienced any other symptoms such as joint pain, fatigue, weight
loss, or nail changes?

 Skin: Any other areas of rash besides the umbilicus and elbows? Any history of similar
rashes before? Have you noticed any changes in the appearance or severity of the rash
over time? Is the rash itchy, red, inflamed, and dry?

 Respiratory: Any ongoing respiratory symptoms from the recent upper respiratory
infection (URI)?

 Psychological: Are you currently under any significant stress or experiencing any major
life changes? How are you coping with stress? Any recent changes in mood or behavior?

 Family History: Further details on her parents' psoriasis, including age of onset and
severity.
Physical Examination:

 A thorough examination of the rash that is located around the elbows and the umbilicus,
taking note of features such as its color, texture, distribution, and the presence of scales.
 Conducting a thorough examination of other parts of the skin to identify any new lesions.
 An examination of the lymph nodes to determine whether or not they have enlarged.
 Examining the nails for any indications of psoriatic alterations is crucial.

Differential Diagnoses

Psoriasis may be confused with superficial fungal infections such tinea corporis or cutaneous
candidiasis. A biopsy with PAS-D stain is useful for distinguishing between psoriasis and a
superficial fungal infection. Using a KOH preparation may aid in diagnosing fungal infections.
Seborrheic dermatitis is a differential diagnosis that can usually be excluded based on certain
aspects of the rash. The rash linked to seborrheic dermatitis is usually thin and oily, often
appearing in particular locations including the eyebrows, nasalabial folds, and behind the ears.
Lichen simplex chronicus may coexist with psoriasis due to excessive scratching (Rajguru et al.,
2020). Psoriasis is often diagnosed with a thorough history and physical examination. In
situations where the clinical examination is inconclusive, a skin biopsy may be conducted to
exclude other potential illnesses. A 4mm punch biopsy is preferred, however a shave biopsy may
suffice in some situations. The specimen is often assessed using a PAS-D stain, which may help
differentiate psoriasis from other disorders (Rajguru et al., 2020).

Risk Factors for Psoriasis

Sally has a number of risk factors for developing psoriasis, perhaps the most contributory being
her genetic predisposition for the disorder. Unfortunately for Sally, psoriasis runs on both the
maternal and paternal sides of her family with both of her parents affected by the disease. It is
common for psoriasis to occur in families, with 40% of patients having a first-degree relative
with it as well (Rajguru et al., 2020). In addition to genetics, behavioural and environmental
factors are also thought to play a role in the development of psoriasis. Both bacterial and viral
infections have been associated with psoriasis flares, and Sally reports just getting over a URI.
Stress has long been thought to be a contributing factor and an exacerbating factor in psoriasis as
well, and Sally reports a high level of stress in her life (Armstrong & Read, 2020).

Treatment Goal and Initial Plan

The main objective of treating psoriasis is to manage the illness and its symptoms (Armstrong &
Read, 2020). The severity of the disease sometimes determines treatment selection. Sally's case
seems to be moderate. I recommend a topical corticosteroid and vitamin D for treating mild,
localized psoriasis since both drugs suit this condition (Rajguru et al., 2020). Recent studies
indicate that combining topical corticosteroids and vitamin D analogs is more beneficial than
using either alone for monotherapy (Armstrong & Read, 2020). In addition, consider including
oatmeal baths or oatmeal-infused skincare products to alleviate itching and inflammation, aloe
vera gel to moisturize and soothe sensitive skin, and Omega-3 fatty acid supplements to
potentially decrease inflammation and enhance skin condition.
Follow-up and Referral

Considering that timely follow-up may lead to improved adherence to topical treatments, I would
make it a point to schedule another appointment with Sally for a follow-up within the next week.
If the specified treatment regimen does not show a noticeable improvement within a month, I
would consider sending her to a dermatologist for further screening and assessment. A referral
will also be justified if the illness worsens or spreads throughout the body or when additional
treatment modalities, such as phototherapy and systemic immunosuppressive drugs, are required
(Armstrong & Read, 2020).

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

Rajguru, J. P., Maya, D., Kumar, D., Suri, P., Bhardwaj, S., & Patel, N. D. (2020). Update on
psoriasis: A review. Journal of Family Medicine and Primary Care, 9(1), 20.
https://doi.org/10.4103/jfmpc.jfmpc_689_19