Mr. Markova’s Case Study
- Based on the information provided thus far, what are your potential diagnoses? Name three and provide confirming and refuting evidence for each one.
|Potential Diagnosis||Confirming Evidence||Refuting Evidence|
|Obesity||The case states that Mr. Markova is obese. Obesity is associated with various skin issues due to several factors. The moisture retained in the body folds of an obese individual encourages the growth of fungi and bacteria, leading to skin rashes. Additionally, the cumulative impact of inflammation on the body of an obese person significantly contributes to the overall fatigue experienced.||Although the case states that Markova is obese, there is no evidence of body mass index (BMI) to rule that he is obese.
Additionally, it is hard for an individual who is obese to stay without seeing a healthcare provider for six years.
Moreover, although an obese person may present with skin rashes and feel fatigued, these symptoms are common with other conditions. They are not primary signs for ruling an obesity diagnosis.
|Intertrigo||Markova has skin rashes in the folds of his skin, which explains why he might be suffering from intertrigo. Moisture trapped in the skin due to sweating causes the skin surfaces to stick together in the skin folds (Cleveland Clinic, 2021).The moisture accelerates the friction, causing inflammation and damage to the skin. When the skin is damaged, it allows the overgrowth of bacteria and fungi. The moisture, warmth, and damaged skin create a suitable environment for the multiplication and growth of bacteria and fungi. The overgrowth triggers the immune system’s response, and the outcome is inflammation and visible skin rash.||Markova only presents with two symptoms of intertrigo, which include a skin rash and itching. For a diagnosis of intertrigo to be made, other symptoms such as feeling pain in the affected area, having a bad smell in the affected area, and having bumps with pus on the affected skin should be considered (Cleveland Clinic, 2021).|
|Contact dermatitis||Markova presented with a rash and itchy feet. Contact dermatitis is associated with an itchy rash due to direct contact with substances or an allergic reaction. Markova could have used a substance such as soap, a fragrance, jewellery, or cosmetics, which caused the skin rash and the itchy feet. Additionally, Markova could have been exposed to an allergen, which caused the skin rash and itchiness.||For a diagnosis of contact dermatitis, the signs and symptoms to be considered include severe itching, a red rash, dry and cracked skin, blisters and bumps, and swelling. However, Markova only had a skin rash on the folds of his skin and itching feet, which ruled out the possibility of him having contact dermatitis.|
- Are there red flag diagnoses that cannot be missed? Explain
The red flag diagnosis that cannot be missed in this case is the skin rashes and being obese. Obesity is a red flag that can be seen visually, and it is a sign that an individual is not eating the appropriate diet. However, what is not seen in obesity is the response inside the body, which puts one athigh risk. In the current society, obesity and being overweight are critical conditions associated with various disorders. Obesity is a severe diagnosis since it is linked to poor outcomes in mental health and decreased quality of life. The condition is associated with the major causes of mortality, including cardiovascular disease, diabetes, stroke, and certain types of cancer. Additionally, being obese cannot be missed because the condition is caused by individual factors such as behaviors and genetics. Behaviors such as lack of involvement in physical activities, dietary patterns, and certain medication increase the risk of being obese. Other contributing factors include skills and education, physical activity and food environment, and marketing and promotion of food. These are factors surrounding individuals, and when they are controlled, the risk of being obese can be reduced. Moreover, the skin rash is a red flag that cannot be missed in this case. A skin rash can be due to a severe allergic reaction or the skin being exposed toa substance. Some allergic reactions are life-threatening, and they can be caused by some medications, foods, insect bites, or latex. A skin rash is an external symptom indicating an allergic reaction, but the response inside the body could be fatal. The reaction may be associated with symptoms such as wheezing, difficulties in breathing, weak pulse, dizziness, and swelling of the tongue and face. Such symptoms are severe and may harm an individual’s health and quality of life.
- What else would you like to ask Bruno before you begin the physical exam?
Markova states that he has never been in the hospital except when he was ten years. This response is limited, and I would like to ask him more questions to uncover some past events relevant to determining his history with hospitalization or other health conditions. I would ask Mr Markova whether he has ever received medical care from the hospital to address problems. I would like to know if he received any medical care. Was it episodic or continuous? I would also like to ask Mr Markova whether he has undergone any medical procedures such as CT scans, MRIs, X-Rays, or any other special testing. Mr Markova may have forgotten what may be considered a significant medical event. As a clinician, I understand that there are patients who may report little history during the interview but reveal complicated series of illnesses to the residents. The patient may not generally conceal the information on purpose, and he only needs to be prompted with the appropriate questions to reveal what is needed. Additionally, I would like to know more about Mr. Markova’s work and hobbies. He states that he works as a salesperson, and I would want to ask whether he has always been doing that job and if he enjoys it. I will enquire whether he has any hobbies or if he is participating in any sports. I would also ask Mr. Markova where he is from originally. Although such questions may not reveal direct information related to his health, it would be essential to have non-medical information about the patient. Such information would help in improving the bond between us and relay the fact that I care about him as a person. The information would provide me with references for later visits, and this would show him that I was paying attention to what he was saying and could remember everything. I would also like to know more about Mr. Markova’s sexual life now that he is divorced. Although this is an uncomfortable path of questioning, it can provide relevant information, and therefore, there is no harm in pursuing it. I would like to know whether he has a stable relationship, engages in sexual intercourse, the partner (same-sex or opposite), if he has a history of sexually transmitted diseases, and whether he uses protection during sexual intercourse.
- What are physical assessment components relevant to your differential? What will you look for and why?
I made the differential diagnoses for Mr. Markova as obesity, intertrigo, and contact dermatitis. The physical assessment components for obesity are essential in determining the extent of the condition. The assessment will also be crucial in determining any overt health concerns. The physical components that I will include for obesity are the measurement of BMI, blood pressure, and waist circumference. Determining the BMI will provide the initial assessment of risk. A BMI below 25 will indicate low risk, while that of more than 25 will indicate a high risk (Sherry, 2021). The first step in the patient’s physical examination will be to identify the vital assessment components, which include waist circumference, BMI, blood pressure, and pulse. The initial action to be taken is determining the weight and height of the patient since these are essential in determining the BMI. Assessment of the BMI helps in categorizing the patient as overweight, pre-overweight, and without complications (Sherry, 2021). It is important to note that the assessment of the BMI needs to be interpreted in the context of a specific ethnicity.Waist circumference, as a vital component of evaluating the obese individual, is appropriate for calculations of central adiposity (Sherry, 2021). It is crucial to obtain careful blood pressure measurements for an obese individual. For intertrigo, the physical assessment components that I would consider in making the diagnosis are the appearance of the skin rash, the location of the rash, and the duration of the inflammation. Since intertrigo initially presents as a mild erythematous patch on both sides where the skin folds, it is imperative to consider how the lesions have progressed during the physical assessment. The rashes for intertrigo may progress to fissures, erosions, weeping, crusting, and maceration. Therefore, examining the type and location of skin rash would be a relevant component of the physical evaluation (Cleveland Clinic, 2021). For contact dermatitis, the relevant components of physical assessments vary depending on the causative irritant or allergen and the affected location in the skin. The relevant components that require examining include the manifestation of erythema and visible borders (Mayo Clinic, 2020). The face, hands and neck need to be checked since they are the common parts affected, although any other part can be affected. Also, checking for discomfort, itching, bullae, vesicles, fissures, lichen with cracks, and dramatic flair may indicate the presence of contact dermatitis.
- Name these skin conditions and treatment you would order, and describe your thoughts on the cause of these rashes relative to this client.
The skin condition presented with the rash under the arms and abdominal folds is intertrigo. The treatment I would order for this condition is maintaining the dryness, cleanliness, and cool of the affected areas. This is the only treatment that will not cause any infection. I would advise the patient to dry the affected area by tapping with a towel after a shower, wearing breathable clothes, using a fan over the affected area multiple times, using a powder-drying agent, and mild antiperspirant. If the intertrigo does not yet have an infection, I would recommend the patient to use skin barrier creams with zinc oxide and fibre skin barriers like clean gauze to reduce friction (Kalra, Higgins, & Kinney, 2014). Topical steroid cream would be appropriate for inflammation, and antifungal or anti-bacterial cream would be essential for combating the overgrowth of bacteria and fungi, which cause inflammation. These rashes are caused by skin-to-skin friction, which is worsened by moisture and heat (Cleveland Clinic, 2021). The moisture causes the skin to stick together, increasing the friction between the skin surfaces, leading to bacterial and fungal overgrowth, skin damage, and inflammation.
The physical examination of his foot indicates that the patient suffers from a skin condition referred to as athlete’s foot or tinea pedis.An athlete’s foot is a fungal infection associated with a stinging, itchy, and burning rash on the skin of the feet (Clevelland Clinic, 2020). The condition tends to be common between the toes. The treatment I would order for this condition includes prescription and over-the-counter antifungal creams, gels, ointments, powders, or sprays. The products contain miconazole, clotrimazole, terbinafine, and tolnaftate (Clevelland Clinic, 2020). I would also recommend antifungal pills containing terbinafine, fluconazole, and itraconazole. The patient must finish the full course of the medication to ensure that the condition does not recur and be hard to manage. Different species of fungi cause athlete’s foot. The physical examination on the eyelid shows a skin condition referred to as xanthelasma. This bumpy, yellow, and fatty deposit forms at the corner of the eyelid. The treatment I would order for this condition would involve options such as cryotherapy (freezing the xanthelasma with liquid nitrogen), laser surgery, traditional surgery, use of chemical peels such as trichloroacetic acid, medication such as statin drug simvastatin, and radiofrequency advanced electrolysis (Fitzgerald, 2017). Xanthelasma is caused by high cholesterol in the body.
- Based on the history and physical findings, what, if any, diagnostic testing would you do? Include your rationale.
The history of Mr. Markova shows that he leads a lifestyle that puts him at an increased risk of obesity. He travels a lot by car, not engaging in physical activities. According to the 24-hr diet recall, the patient does not seem to follow a healthy diet. He has a family history of myocardial infarction, hypertension, and diabetes mellitus. Additionally, he presents with skin rashes in skin folds in his arms and abdomen, rashes on the feet, which are itchy, and a yellowish patch in the eyelids. All the symptoms lead me to perform diagnostic testing on obesity using the body mass index scale. The diagnostic testing for this condition may also involve lab tests to assess the degree to which the condition affects the patient’s overall health. The lab tests that I may consider include cholesterol levels, fasting blood sugar, and haemoglobin to determine symptoms of diabetes and a liver function test to determine the potential of occurrence of fatty liver disorder.
- What is the significance of the lab results?
The lab results for cholesterol levels, fasting blood sugar, and hemoglobin AIc tests indicate abnormalities and they are considered essential for diagnosing diabetes, obesity, and cholesterol levels. The lab results indicate the conditions the client has. The lab results will help identify the correct diagnosis, and therefore, it will be easier to administer the appropriate treatment. The lab tests play a critical role in detecting the disease early, diagnosing it, and providing a treatment plan. Routine submission of the patient to the lab tests allows the healthcare providers to respond quickly with appropriate treatment measures, which may save time and money the patient, could use in managing the condition. A lab test is among the initial lines of defense for the protection of the patient’s general well-being. The lab tests will be essential in determining the patient’s experiences with the condition and the type of healthcare services he will receive.
- Assess his cardiac risk using the Framingham Risk Score Calculator. Does Bruno’s family history impact how you would rate his risk score? Briefly explain.
Mr. Markova’s 10-year risk of MI or death is 24.5%. The Framingham Risk Score Calculator has evolved as a powerful tool for assessing the risk for cardiovascular diseases. Recently, tables have been established in the risk score calculator to help predict the various aspects of cardiac risk. The modifiers for the new Framingham algorithms include family history. Positive family history is defined if the patient reports first-degree relatives to have hypertension, obesity, CVD, and diabetes (Santos, Rodrigues, Rosa, Sarrafzadegan, & Silveira, 2020). Mr. Markova has a history of cardiovascular disease, CVD, diabetes, and hypertension from his father and paternal grandfather, and this factor is likely to increase his risk score for a cardiac disorder.
- What are your diagnoses now? Make full diagnostic statements for all the health issues you have identified. Briefly list the rationale.
My diagnosis for Mr. Markova is that he is suffering from obesity, diabetes, and high cholesterol.
- Health issue 1- Mr. Markova presents with skin rashes in the folds of his skin. An obese patient is vulnerable to moisture-associated damage to the skin. Additionally, intertrigo is a common complication of diabetes (Vakharia, 2020). The reason is the compromise in the natural cooling techniques of his body, which causes their sweat to be a virtual constant. Additionally, the body mass of the patient limits his mobility. The accumulation of the moisture, which remains trapped in the skin folds, increases the growth of fungi, bacteria, and viruses, which leads to skin rashes.
- Health Issue 2 – Mr. Markova complains of itchy feet. Obesity is one of the risk factors associated with developing itchy feet. The increased body weight of an obese person is exerted on the feet, increasing the heat and sweating in the feet. As a result, the moisture and heat trap fungi in the toes, causing a fungal infection in the feet, usually itchy. Additionally, diabetes is associated with fungal infections and this explains the athlete’s foot in the patient, which causes the itchiness.
- Health Issue3 – Mr. Markova presents with being fatigued most days. The primary mechanism that may make the obese person feel tired is long-term, low-grade inflammation. The fat cells originating from the abdominal fats are known to produce immune compounds, referred to as cytokines. These immune compounds lead to sleepiness among people with obesity. Being overweight contributes to what is currently referred to as excessive daytime sleepiness (EDS) (Fernandez-Mendoza, Vgontzas, Kritikou, Calhoun, Liao, & Bixler, 2015). The condition is associated with chronic tiredness, a multi-faceted issue with multiple contributing factors connected to obesity.
- Health Issue 4 – Mr. Markova has xanthelasma as indicated by the yellow bump on his eyelid. The skin bump occurs when an individual has high cholesterol in the blood and diabetes (Iftikhar, 2018). The bumps contain fats.
- What are the priorities of care today, and what will you prescribe? Write a prescription for one of his new medications and place it in the appendix.
The priorities of care today for obesity involve identifying inappropriate behaviors that cause the condition, preparing a suitable diet plan, providing relevant information, and determining knowledge on nutrition. The primary priority for caring for Mr. Markova is adopting a plan towards changing his lifestyle. The management and treatment of obesity aim at reducing the health risks associated with the disease (Sherry, 2021). A weight management program that incorporates a healthy diet, physical exercise and a change in daily activities is recommended. The program may also include psychological counselling and drug therapy. What is important in managing obesity is eating a healthy and balanced diet (Sherry, 2021). Fad and crash diets should be avoided since they are not successful in the long term. When the diet is ceased, the weight usually returns. Successful loss of weight and maintaining a healthy weight requires long-term changes in exercise and eating behaviors. It also requires an understanding of the emotional elements that cause overeating. Current care plans for obesity involve setting and attaining realistic goals. Physical activity is encouraged in obesity care programs since it does not only help in the management of weight and the improvement of overall health. It enhances a reduction in the risk of disorders such as cardiovascular disease, certain types of cancer, and osteoporosis. Medications are also part of the current weight management programs. Medications are used together with proper exercising and diet. Medications are usually for individuals who have been classified as obese (BMI over 30) or those with a BMI of 27 and cardiovascular disease risk factors such as diabetes or cholesterol (Sherry, 2021). An example of a medication recommended for weight loss is orlistat. The drug blocks fat absorption from the bowel. Liraglutide is a drug used primarily for the treatment of type II diabetes, but it can be used for weight loss since it reduces appetite and intake of food. Additionally, Naltrexone can be combined with bupropion to facilitate weight loss. Naltrexone suppresses appetite, and bupropion alters certain chemicals in the brain, which are associated with reduced food intake. Current care may also consider surgery if other options of managing weight have been unsuccessful.
The priority care for diabetes and high cholesterol levels involves lifestyle changes. For diabetes, healthy eating and physical activities should be part of the daily routine to maintain healthy weight (Mayo Clinic, 2022). The patient should monitor blood sugar by following the instructions provided by the healthcare provider on how to manage blood sugar. Care for diabetes also requires proper management of blood pressure to avoid damage of the blood vessels. Managing levels of cholesterol is essential care for the diabetic patient since the resulting damage is worse. Managing high levels of cholesterol requires the patient to eat a healthy diet with reduced fats, avoid excess alcohol, and engage in regular exercises (Mayo Clinic, 2022). Medications are also part of priority care for both diabetes and high cholesterol. Various factors such as age, patient’s health, and possible side effects need to be considered before administration of medication.
- What are the short-term management goals for Bruno? Provide a rationale for the decision.
The goal of treatment and management of obesity should be minimizing or reducing the complications associated with the disease and improving the quality of life. The goals should include comprehensive lifestyle interventions, which incorporate physical activity, an eating plan, and training behavioral skills to support the changes. The short-term management goals for Mr. Markova include:
- Determining the inappropriate behaviors and the consequences associated with him being obese.
- Enhancing changes in Mr. Markova’s eating patterns and his involvement in active physical exercise
- Reducing the skin rash and the itchy feet using appropriate treatment
- Enhancing weight loss of Mr. Markova with optimal health maintenance
- What surveillance needs to be done to monitor chronic complications from his disease? Categorize them as primary, secondary, and tertiary prevention.
|Primary prevention||Secondary prevention||Tertiary prevention|
|· When the attention is focused on a multifactorial condition such as heart disease, the primary prevention would involve a national programme to control levels of blood cholesterol.
· Implementation of measures at all levels in various environments.
· Establish evidence-based prevention programs in pre-schools, elementary schools, healthcare clinics, and community settings.
|· Reducing the risk of heart disease among those with high blood cholesterol levels
· Preparation of plan for treatment
· Educating and explaining the disease and the importance of changing physical activities and nutrition to the people.
|· Prevention of re-infarction for individuals with a previous heart attack
· Activities and measures for prevention of disease progression
· Using pharmacological therapy and bariatric surgical procedures to manage obesity
Cleveland Clinic. (2021). Intertrigo. https://my.clevelandclinic.org/health/diseases/21693-intertrigo#symptoms-and-causes
Clevelland Clinic. (2020). Athlete’s foot (Tinea Pedis). https://my.clevelandclinic.org/health/diseases/22139-athletes-foot-tinea-pedis#management-and-treatment
Fernandez-Mendoza, J., Vgontzas, A. N., Kritikou, I., Calhoun, S. L., Liao, D., & Bixler, E. O. (2015). Natural history of excessive daytime sleepiness: Role of obesity, weight loss, depression, and sleep propensity. Sleep, 38(3), 351-360.
Fitzgerald, N. (2017). What isxanthelasma?https://www.healthline.com/health/xanthelasma#risk-factors
Iftikhar, N. (2018). Eruptive xanthomatosis. https://www.healthline.com/health/eruptive-xanthomatosis#:~:text=Eruptive%20xanthomatosis%20(EX)%20causes%20small,bumps%20are%20filled%20with%20fat.
Kalra, M. G., Higgins, K. E., & Kinney, B. S. (2014). Intertrigo and secondary skin infections. American Family Physician, 89(7), 569-573.
Mayo Clinic. (2020). Contact dermatitis. https://www.mayoclinic.org/diseases-conditions/contact-dermatitis/symptoms-causes/syc-20352742#:~:text=Contact%20dermatitis%20is%20a%20red,%2C%20fragrances%2C%20jewelry%20and%20plants.
Mayo Clinic. (2022). Diabetes care: 10 ways to avoid complications. https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-management/art-20045803#:~:text=Make%20a%20commitment%20to%20managing%20your%20diabetes&text=Make%20healthy%20eating%20and%20physical,by%20your%20health%20care%20provider.
Santos, A. S., Rodrigues, A. P. S., Rosa, L. P., Sarrafzadegan, N., & Silveira, E. A. (2020). Cardiometabolic risk factors and Framingham Risk Score in severely obese patients: Baseline data from DieTBra trial. Nutrition, Metabolism and Cardiovascular Diseases, 30(3), 474-482.
Sherry, C. (2021). How obesity is diagnosed. https://www.verywellhealth.com/how-obesity-is-diagnosed-4690037#:~:text=2-,Body%20Mass%20Index%20(BMI),one’s%20height%20(in%20meters)
Vakharia, P. (2020). Intertrigo. https://emedicine.medscape.com/article/1087691-overview
Appendix 1: SOAP for Bruno Markova
Time: 11.00 am
Mr. Markova reported that he was obese and had not seen a doctor for six years. He reported feeling well until the last there months when he started developing skin rashes at the folds of his skin, feeling tired and itchy feet. Mr. Markova reported no allergies, does not smoke, only drinks 2 to 3 beers on weekends, and does not use any drugs. He says he lost 20lbs this year, and he is often thirsty.
Age=54yrs ,Sex= male ,Wt.=98kg , Ht.= 172cm, BP 140/90, HR 78 and regular, RR 20, T 36.8.
Fasting blood glucose 16.8 (9 hours fasting)
Triglycerides 2.13mmol/L (0.00-1.70)
Non-HDL cholesterol 4.31mm/L (0.00-4.20)
Mr. Markova reports not being on any medication
Mr. Markova is a 54-year-old obese man with skin rash, itchy feet, and fatigue on most days. He has a family history of cardiovascular disease and diabetes, which puts him at a high risk of the disease. He reports that he has not been using any medication or being hospitalized for a long time now.His 24-hour diet recall shows that his diet is not healthy, which increases the risk of his condition.
- Introduce him to a weight loss program and set small, frequent, healthy meals for him.
- Encourage the patient to follow the diet strictly and ensure he is involved in physical exercises.
- Advice him to stop drinking
- Educate him on how to care for the skin rashes to avoid recurrence.
Appendix 2: Prescription
- For Mr. Markova, I would prescribe orlistat with a reduced caloric diet and physical exercises.
Orlistat 120mg: To be taken three times per day with every meal containing some fat. Taken with either the meal or one hour after eating
- I will prescribe skin barrier creams combined with maintained dryness and cool of the affected area for the skin rash. For the itchy feet, I would prescribe anti-fungal cream.
- I will also prescribe insulin for diabetes (at least two shots a day depending on control of blood sugar) and statins (atorvastatin 80mg per day) to lower cholesterol levels.