Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A five-year-old year old otherwise well-child presents with a 4-day history of a skin problem. She's without fever and no acute distress. Her parents advise that other children in the child's playgroup have developed similar skin lesions. Considering the diagnosis of non-bullous impetigo, the NP expects to find which of the following:
A: A four-centimeter, round, honey-crusted lesion surrounded by about a 0.5 centimeter area of erythema, localized to the chin.
B: Multiple papular skin lesions about 0.25 centimeters in diameter, with burrow marks in a linear fashion on both arms.
C: A generalized vesicular rash over the trunk and extremities.
D: Areas of lichenification in the antecubital fossa.
The correct answer is A: A four-centimeter, round, honey-encrusted lesion, surrounded by about 0.5 centimeter area of erythema, localized to the chin.
Where should you start? First, determine what type of question this is. Given this question is focused on information gathering, this is an assessment question. The information gathered during assessment, with both subjective and objective information, form the basis for arriving at the correct diagnosis. Let's start with some background information. Non-bullous impetigo is a common superficial skin infection, most often seen in children aged 2 to 5 years.
This condition starts with papules that then evolve to pustules over a few days. The term ‘non-bullous’ is used because there are not the large vesicles or blisters that would meet the criteria for the bullous form of the disease. Once the child gets through the papular to pustular stage, the next stage involves breaking down of the pustules to form a thick, adherent crust.
These crusts are typically gold or sometimes referred to as being honey-colored, most commonly on the face and arms. A single lesion is occasionally noted, although multiple lesions are possible and usually the skin areas that are open and not covered by clothing are most affected. The diagnosis is made clinically, usually without cultures given that the causative organisms are quite predictable.
Other tests aren't needed because the child is typically not systemically ill. What are some of the key assessment components of a germ condition, impetigo, specifically? And some of these points I'm going to hit on will overlap with skin conditions regardless of the person's age. A primary role in dermatology is to assess the entire patient and not just the skin.
With that in mind, let's take a look at the information presented. And here are some of the questions that you should always ask any person with a derm condition. First, is a patient otherwise well? In this scenario, we're told that she's without fever and is no acute distress. This implies a condition that's limited to the skin. Non-bullous impetigo is usually limited to a few lesions and a child with the condition is generally otherwise well.
Sometimes with impetigo the child might have complained of the lesion being itchy or a little irritated. In a pre-verbal child, you'll see them rub the lesion quite often, but it's not tremendously painful. Fever, GI, and other more systemic symptoms are just not found. Is there evidence of contagion? This child spends time in a group setting, the playgroup that's mentioned, where other kids have similar skin lesions.
Impetigo, usually caused by Streptococcus pyogenes, and less commonly by Staph aureus, is highly contagious. The contagion issue is one reason why the lesions are usually limited to skin areas that are not covered by clothing. And if you've ever been with a group of kids in this age group and see them play together, it is like watching a pack of puppies on the floor.
They will sometimes roll around with one another. They are doing skin-to-skin contact with one another and sometimes their hand hygiene is not quite as meticulous as we would like to see. So, playgroups are wonderful, enriching experiences for kids. At the same time, this is sometimes where kids pick up illnesses like this. Next question to always ask is, what the patient's risk for a given diagnosis.
I reinforce this time and time again in these, I guess. As was mentioned, impetigo is most common in kids ages 2 to 5 years. And it’s particularly found in children in group care. Considering the disease’s epidemiology is key to safe and effective practice and will really help you hone down and further refine your differential diagnosis skills to keep that in mind.
And what's the typical distribution of the skin lesions? As mentioned, in non-bullous impetigo, the lesions are almost always on the face and extremities. In other words, parts of the body where wearing clothing doesn't cover the skin. With this information in mind, let's take a look at the question and the possible answers, and shed more light on what's the correct response, annd in fact, that will also be the best response.
A five-year-old otherwise well-child presents with a 4-day history of a skin problem. She's without fever and in no acute distress. Her parents advise that other children in their child's playgroup have developed similar skin lesions. Considering the diagnosis of non-bullous impetigo, the NP expects to find which of the following:
A: A four-centimeter, round, honey-crusted lesion surrounded by an approximately 0.5 centimeter area of erythema, localized to the chin.
Of course, this is the correct response. It's also a fairly classic presentation of non-bullous impetigo. On the NP boards, you're most likely going to get questions that are reflective of classic presentation of the condition.
Option B: Multiple papular skin lesions approximately 0.25 centimeters in diameter, with burrow marks in a linear fashion on both arms. Option B describes the classic presentation of scabies.
Yes, we have a scenario where we're told other kids in her playgroup have similar skin lesions and of course scabies are contagious. But here the distribution is incorrect for impetigo, or at least a lot less common presentation of impetigo. And we're also told this child has a single skin lesion. Scabies simply does not present as a single skin lesion.
There will be multiple lesions and they often do start off as papular skin lesions that are about 0.25 centimeters in diameter with the characteristic burrow marks. The arms are a very common place for scabies to show up, and the faces is actually, a really uncommon location for scabies. Scabies typically doesn't give you those honey-crusted lesions that we're hearing about here.
C: Generalized vesicular rash over the trunk and extremities. A generalized vesicular rash over trunk and extremities really sounds more like varicella or some other form of viral exanthem. By the way, viral exanthem is simply a fancy way of saying it is a rash that accompanies a viral illness. Kids are far more likely to have skin lesions with a viral infection than adults are.
You would expect that if this child had a viral exanthem, we would also hear that the child didn't feel well, had fever, because this represents the dermatologic manifestation of a systemic illness. Of course, with the varicella vaccine, not mentioned in this question, whether this little one is immunized or not, has rendered varicella from a ubiquitous childhood disease to one that's thankfully seldom seen in this country.
The areas of lichenification in the antecubital fossa. This is, of course, not correct. And this describes the clinical presentation of eczema. The antecubital fossa bilaterally is one of the most common locations for eczema in a child of this age or older. Often the lesions do become lichenified, and this is in part because the areas are really itchy.
So, the child rubs it a lot and that triggers lichenification. And I'm sure you're aware eczema is one of the atopic diseases and is not contagious. Clearly, in this question, we're looking for something that is contagious because other kids in their playgroup have similar skin lesions. I've said this before, I'm going to say it another time. Every single word in the exam question is important and is going to aim you towards the correct choice.
Key takeaway: the differential diagnosis in skin lesions in any age group is an important part of clinical practice. It also tends to be one of the most daunting challenges we come across as clinicians, keeping in mind that strong assessment skills, gathering the appropriate subjective and objective of information, considering what risk group the patient is in for certain skin conditions, then pulling it all together with strong analysis and synthesis skills, you will come up with the right answer on the NP boards and the right answer in the exam room.
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