1a) Identify two (2) additional questions that were not asked in the case study and should have been?
The healthcare provider did not ask enough questions regarding exposure to substances that could lead to Mr. Fitzgerald’s skin problem. “Have you been exposed to chemicals or irritants and for how long?”
Another question that was not asked is about how the patient has managed his skin condition for the past four years. “Have you used any medications before to manage the skin problem?”
1b) Explain your rationale for asking these two additional questions.
The patient’s skin condition indicates probable exposure to irritants or chemicals that can predispose individuals to skin cancer (Fania et al., 2021). Obtaining the type of chemicals that the patient was exposed to during work before and after retirement could aid in formulating differentials. It is also important to know the remedies that the patient has used for the past four years to manage his skin condition. This information could help the primary care provider identify alternative therapies during the formulation of the treatment plan.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.
Asking these two questions will reveal the probable cause of the skin lesion and guide the provider in formulating differential diagnoses. For example, if Mr. Fitzgerald reports exposure to chemicals and irritants, it will lead to questioning of skin cancer. The question on medication use will indicate worsening of the skin lesion due to failed response to treatment. Additionally, the healthcare provider will understand how the patient cares about his health if he reports not using any medications or seeking medical attention.
DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
Physical examination is an important step during diagnostic evaluation because it can help in confirming a suspected diagnosis. A careful examination can refine the steps of the diagnostic process and prevent unnecessary testing. It was important for the healthcare provider to perform a physical examination to ascertain the patient’s health status and discover any other complaints. Taking vitals was the first step for the provider to get a glimpse of the overall well-being of the patient while examination of the other systems served to determine deviations from normal health in relation to the presenting complaints.
2b) Describe how the exam findings would be abnormal based on the information in this case.
The patient’s skin was examined from head to toe, including the scalp, soles, and palms. Abnormal findings on examination were observed on his left forearm where an oval erythematous patch measuring 35 X 25 mm was observed.
2c) Describe the normal findings for each system.
The first part of the physical exam involved taking the vital signs. Mr. Fitzgerald’s vitals were as follows: Temperature 36.8 °C, Pulse 64 beats/ minute, Respiratory rate 18 breaths/minutes, and Blood pressure 124/76 mmHg. Examination of the head, eyes, ears, nose, and throat (HEENT) revealed unremarkable results. There was a regular heart rhythm without a murmur on examination of the cardiovascular system while abdominal examination revealed a well-healed linear scar on his left upper quadrant. The patient had a splenectomy done several years ago that left the scar.
2d) Identify the various diagnostic instruments you would need to use.
Examination of the patient’s vitals will require the use of a stethoscope, blood pressure machine, and a thermometer. A penlight will be needed for ear and eye examination. To examine the skin and determine the size of the skin patch, a ruler and tape measure will be required.
DOMAIN: ASSESSMENT (Medical Diagnosis) Discuss the pathophysiology of the:
3a) Diagnosis and,
Upon examination and testing, Mr. Fitzgerald was diagnosed with cutaneous squamous cell carcinoma. Squamous cell carcinoma (SCC) is the second most common form of skin cancer characterized by the abnormal accelerated growth of squamous cells (Fania et al., 2021). Squamous cells are flat cells located near the surface of the skin and continuously shed as new ones are formed. Most SCCs of the skin results from prolonged exposure to ultraviolet (UV) radiation either from sunlight or tanning beds or lamps. During prolonged exposure to UV radiations, deoxyribonucleic acid (DNA) is damaged. One critical pathogenic event was observed in the development of apoptotic resistance through the loss of TP53 which functions to suppress tumors (Fania et al., 2021). Continuous exposure to UV radiation further damages keratinocytes leading to clonal expansion. The result is invasive cutaneous cell carcinoma that appears as scaly red patches, open sores, or thickened skin.
3b) Each Differential Diagnosis
Based on the patient’s presentation, eczema is among the first differentials to consider. The condition is characterized by red and itchy skin and is commonly observed in children but can occur at any age (Boothe et al., 2017). Although the mechanism of its development is not well-established, studies indicate that skin barrier dysfunction and immune dysregulation contribute to the development of the disease. The disruption of the skin barrier can be caused by genetic alterations of the filaggrin gene that leads to the development of ichthyosis (Boothe et al., 2017). Apart from this mechanism immune system dysfunction especially Th2 cytokines can inhibit filaggrin expression causing epidermal barrier impairment. The result of these interactions is inflammation and eczematous skin lesions on the neck and hands accompanied by dry skin.
Mr. Fitzgerald’s clinical presentation can also be interpreted as a diagnosis of aktinic keratosis. This condition is the most common precancer that forms on skin damaged by chronic exposure to ultraviolet rays from the sun or indoor tanning. Excessive exposure to UV radiations can induce several pathologic changes to the epidermal keratinocyte including leading to disruption of regulatory pathways. The result is inflammation and immunosuppression that causes intraepidermal proliferation giving rise to the disease. Lesions frequently appear on areas exposed to the sun like lips, ears, neck, hands, and forearms.
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
4a) What labs should be ordered in the case?
There are no specific laboratory tests for the diagnosis of squamous cell carcinoma. No laboratory investigations should be ordered for Mr. Fitzgerald because the location of the lesion is local and does not seem to bother him.
4b) Discuss what lab results would be abnormal.
No abnormal labs in this case.
4c) Discuss what the abnormal lab values indicate.
No abnormal labs in this case
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
The diagnostic procedure I might want to order is a punch biopsy of the skin. A punch biopsy is considered the primary technique to obtain diagnostic, full-thickness specimens (Skin Cancer Foundation, 2021). This diagnostic procedure is useful for the discovery of cutaneous neoplasms like basal cell carcinoma, melanoma, and squamous cell carcinoma.
5a) What is the function of the skin?
The skin is the largest organ in the body and has several functions. The skin functions to protect the body against trauma. It regulates body temperature, maintains water and electrolyte balance, and participates in the synthesis of vitamin D (Gilaberte et al., 2016). As a sensory organ, the skin has nerve fibers that detect temperature, pressure, vibration, touch, and injury.
5b) What are the risk factors for skin cancer?
Anybody can get skin cancer, but certain factors put individuals at risk of the disease. According to the Centers for Disease Control and Prevention (CDC) (2021), people with lighter natural skin color are at greater risk of getting the disease. Likewise, those with skin that burns or reddens easily, blue or green eyes, blond or red hair, family history of skin cancer, and older age can easily get the disease.
Boothe, W. D., Tarbox, J. A., & Tarbox, M. B. (2017). Atopic dermatitis: Pathophysiology. Management of Atopic Dermatitis, 21-37. https://doi.org/10.1007/978-3-319-64804-0_3
Centers for Disease Control and prevention. (2021). Skin cancer: What are the risk factors? https://www.cdc.gov/cancer/skin/basic_info/risk_factors.htm
Fania, L., Didona, D., Di Pietro, F. R., Verkhovskaia, S., Morese, R., Paolino, G., Donati, M., Ricci, F., Coco, V., Ricci, F., Candi, E., Abeni, D., & Dellambra, E. (2021). Cutaneous squamous cell carcinoma: From pathophysiology to novel therapeutic approaches. Biomedicines, 9(2), 171. https://doi.org/10.3390/biomedicines9020171
Gilaberte, Y., Prieto-Torres, L., Pastushenko, I., & Juarranz, Á. (2016). Anatomy and function of the skin. In Nanoscience in Dermatology (pp. 1-14). Academic Press. https://doi.org/10.1016/B978-0-12-802926-8.00001-X
Skin Cancer Foundation. (2021). Squamous cell carcinoma: Overview. https://www.skincancer.org/skin-cancer-information/squamous-cell-carcinoma/#:~:text=Squamous%20cell%20carcinoma%20(SCC)%20of,squamous%20cell%20carcinoma%20(cSCC).
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