Scaly Plaques and a Swollen Finger: A Focused Dermatologic and Musculoskeletal Assessment of a 44-Year-Old Electrician
[Student Name]
University of Phoenix
NSG/523: Advanced Health Assessment
Week 2 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. No real patient, clinician or practice is described.
Subjective
The patient is a composite 44-year-old right-handed man who works as a commercial electrician. He came to a nurse practitioner led primary care clinic because his left index finger has been swollen and painful for six weeks, making it hard to grip tools and strip wires. The swelling involves the whole finger, which he describes as looking like a sausage. The pain is aching, rated 5 out of 10, worst in the morning and improving after he has used his hands for about an hour. He also reports stiffness in both hands on waking lasting about 45 minutes and pain at the back of his right heel when he climbs ladders. Ibuprofen 400 mg helps partially. He recalls no injury, insect bite or cut to the finger.
He has had itchy, scaly patches on his elbows, knees and scalp for five years, which he has treated intermittently with over-the-counter hydrocortisone cream without much change. He had never connected the patches on his skin with his finger until the nurse practitioner asked about them, and he had not mentioned them because he thought they were only dry skin. He has noticed small dents in his fingernails over the past year.
Review of systems: he denies fever, weight loss, eye redness or pain, mouth ulcers, diarrhea, abdominal pain, urinary symptoms or penile discharge, and low back pain that is worse with rest. He has no history of recent sore throat or sexually transmitted infection.
Past medical history includes obesity and elevated blood pressure readings not yet treated. He takes no prescription medicines. Family history: his mother has psoriasis. Social history: he has smoked about ten cigarettes daily since his twenties and drinks four to six beers on weekends.
Objective
Vital signs: temperature 36.7 C, blood pressure 146/92 mm Hg, pulse 80, respirations 16, weight 108 kg, height 1.80 m, body mass index 33.3.
Skin: well-demarcated, erythematous plaques with thick silvery-white scale on the extensor surfaces of both elbows, 6 by 4 cm on the right and 5 by 3 cm on the left, and on both knees, 7 by 5 cm on the right and 4 by 4 cm on the left. Removing scale gently from one plaque showed pinpoint bleeding. Similar plaques are present along the posterior scalp hairline and in the gluteal cleft. Using the palm of the patient's hand as about 1% of body surface area, the total involvement is estimated at about 4%. No pustules, erosions or signs of secondary infection. Assessment texts recommend describing lesions by type, size, color, surface features and distribution rather than by diagnosis, so the record can be compared over time (Bickley et al., 2021).
Nails: pitting on six fingernails, about 15 pits in total, and distal onycholysis of the left index and right middle fingernails. No subungual hyperkeratosis.
Musculoskeletal, hands: the left index finger is diffusely swollen from base to tip, warm and tender along its length, with limited flexion at the proximal and distal interphalangeal joints; he cannot make a full fist on the left. The distal interphalangeal joints of the left middle and right ring fingers are mildly swollen and tender. The other hand joints show no synovitis. Grip strength is reduced on the left.
Musculoskeletal, feet and spine: tenderness at the insertion of the right Achilles tendon on the calcaneus, without swelling of the tendon itself. No plantar fascia tenderness. The lumbar spine has full range of motion, and a modified Schober test shows 5 cm of excursion. Sacroiliac joints are nontender.
Eyes: no conjunctival injection.
Cardiovascular and abdomen: regular rhythm without murmur; abdomen soft and nontender. These were examined because psoriatic disease carries higher cardiometabolic risk, and a baseline is useful before systemic treatment.
The musculoskeletal examination followed the sequence of inspection, palpation, range of motion and special tests, comparing each side with the other (Ball et al., 2023).
Assessment
The working impression is psoriatic arthritis with dactylitis, distal interphalangeal arthritis and Achilles enthesitis, in a patient with chronic plaque psoriasis involving about 4% of body surface area and psoriatic nail disease.
The Classification Criteria for Psoriatic Arthritis require inflammatory articular disease plus at least 3 points from a set of features (Taylor et al., 2006). This patient has inflammatory articular disease in the hand joints and entheses, and the recorded findings supply current psoriasis (2 points), typical nail dystrophy with pitting and onycholysis (1 point) and current dactylitis (1 point), for 4 points before any laboratory or radiographic result. A negative rheumatoid factor and new bone formation near joints on hand radiographs, if present, would add points. Psoriatic arthritis is common among people with psoriasis; Ogdie and Weiss (2015), reviewing its epidemiology, reported that a substantial minority of people with psoriasis develop it, and nail disease is associated with greater risk. Ritchlin et al. (2017) describe dactylitis, enthesitis and distal joint involvement as distinguishing features of the disease.
The differential diagnosis is ranked by findings. Rheumatoid arthritis is less likely because the involvement is asymmetric, includes distal joints and entheses and is accompanied by psoriasis and nail changes, though rheumatoid factor and anti-citrullinated peptide antibodies will be checked. Gout can cause a swollen digit and is common in men with obesity and alcohol use, so a serum uric acid will be obtained, but the six-week course, distal joint pattern and skin findings fit psoriatic disease better. Reactive arthritis is less likely with no preceding infection and no urethral or bowel symptoms. Septic tenosynovitis was considered because of the swollen, warm finger but is unlikely without fever, a wound or rapidly progressing pain.
Plan
Laboratory tests include a complete blood count, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, anti-citrullinated peptide antibodies, uric acid, a comprehensive metabolic panel and a lipid panel. Radiographs of both hands and the right heel will look for erosions and new bone formation. The patient will be referred to rheumatology, since early disease-modifying treatment can prevent joint damage, and to dermatology or started on a topical corticosteroid for the plaques in the meantime. His blood pressure will be rechecked in two weeks, and smoking cessation and moderation of alcohol will be discussed, since both relate to his disease and to the cardiovascular risk that accompanies it.
Why the Two Systems Belong Together
This case shows why the dermatologic and musculoskeletal examinations are taught side by side. On its own, the swollen finger could have been treated as an injury or gout, and the plaques could have remained "dry skin." Examined together, the skin, nails, fingers and heel form a single pattern that points to one diagnosis and to a treatment that addresses both.
Conclusion
A focused history and examination of the skin, nails and joints revealed plaque psoriasis, nail pitting, dactylitis, distal joint arthritis and enthesitis in a 44-year-old man who had not connected his skin with his finger. Measured lesions, a systematic joint examination and the classification criteria together support psoriatic arthritis as the working impression, with a plan to confirm it and refer early.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Ogdie, A., & Weiss, P. (2015). The epidemiology of psoriatic arthritis. Rheumatic Disease Clinics of North America, 41(4), 545-568. https://doi.org/10.1016/j.rdc.2015.07.001
Ritchlin, C. T., Colbert, R. A., & Gladman, D. D. (2017). Psoriatic arthritis. New England Journal of Medicine, 376(10), 957-970. https://doi.org/10.1056/NEJMra1505557
Taylor, W., Gladman, D., Helliwell, P., Marchesoni, A., Mease, P., & Mielants, H. (2006). Classification criteria for psoriatic arthritis: Development of new criteria from a large international study. Arthritis & Rheumatism, 54(8), 2665-2673. https://doi.org/10.1002/art.21972
How this NSG 523 Week 2 example is structured
The University of Phoenix library guide for NSG/523 lists Week 2 as Dermatological and Musculoskeletal Assessments. The write-up treats the two systems as one problem, because the most important finding in this patient is the connection between his skin and his joints. Skin lesions are described with the standard vocabulary of morphology, distribution and extent, the joint examination moves through inspection, palpation, range of motion and special findings, and the assessment ties each criterion for the diagnosis to a recorded finding. Students search this week as NSG 523 Week 2, NSG523 Wk 2 or NSG/523 Wk 2; all three are the same assignment.
NSG/523 Week 2 questions, answered
What does NSG/523 Week 2 usually ask for?
The University of Phoenix library guide for NSG/523 lists Week 2 as dermatological and musculoskeletal assessments. Many sections ask for a focused history and examination write-up of a skin or musculoskeletal complaint with a supported differential diagnosis. Your instructions and rubric decide the exact form and whether a care plan is included.
How do I describe a skin lesion correctly?
Name the primary lesion type (macule, papule, plaque, vesicle and so on), its size in centimeters, color, border, surface change such as scale, arrangement and distribution, and estimate the body surface area involved. Vague terms such as "rash" do not earn credit in an advanced assessment write-up.
What is dactylitis?
Dactylitis is diffuse swelling of an entire finger or toe, often called a sausage digit, caused by inflammation of the joints, tendon sheaths and soft tissue together. It is a characteristic finding in psoriatic arthritis and helps distinguish it from other forms of arthritis.
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