NURS-6512 Differential Diagnosis for Skin Conditions SOAP note

Comprehensive SOAP Template

Patient Initials: AC                             Age: 68                                   Gender: Male

 

SUBJECTIVE DATA: “About a week ago, I noticed some rash on my right chest, back, and neck. I thought it would get better, but the rash is itchy and painful, it has also gotten worse. I also feel a little feverish.”

Chief Complaint (CC): The patient reported noticing skin abnormality about a week ago, “I have an itchy rash on my neck, chest, and back that is peeling and getting worse.” The rash is swollen with clear liquid and painful.

History of Present Illness (HPI):  Mr. Alexander Cortez is a 58-year-old Hispanic male. Presents with a patchy rash on the neck, chest, and back region. He states that the rash started about two weeks ago and has progressively gotten worse. He denies changing skin routine or location within the last two weeks, no history of environmental allergies, no known allergy to dye, or latex. Mr. Cortez states he has not tried any treatment for the rash, no worsening, or alleviating factors noted. He complained of pain level 7 on a scale of 1-10. He describes the pain as sharp and states Tylenol 1000mg has helped relieve the pain. He is worried about the rash getting worse and states that the rash and its associated pain interferes with his daily activities and quality of life.

Medications:  

– Acetaminophen 1000mg

PO Q 6 HRS for pain

– Metformin 500mg daily for diabetes

– Atorvastatin 40mg at bedtime for high cholesterol

– Hydralazine 10mg BID for Hypertension

– Amlodipine 5mg daily for hypertension

Allergies: 

– Penicillin Reaction (itching)

Past Medical History (PMH): 

  1. Hypertension-diagnosed at 43 years old
  2. Hyperlipidemia- diagnosed at 45 years old
  3. Diabetes Mellitus Type 2 diagnosed at 38 years old
  4. Chickenpox: 7 years old
  5. Appendicitis – hospitalization at 28 years old

Past Surgical History (PSH): 

Appendectomy 1992

Sexual/Reproductive History: 

Currently sexually active with his wife, he denies sexual/reproductive issues. Heterosexual and currently using no barrier methods, no past history of STDs.

Personal/Social History: 

The patient is a non-smoker, never smoked. His wife smokes 1pack/day. Mr. Cortez drinks alcohol occasionally, about 1-2 drinks a week. He denies the use of recreational drugs.

Immunization History: 

Received flu shot last season

Received pneumococcal vaccine 8/12/2019 during the annual check-up

He does not remember the last tetanus vaccination.

Significant Family History:

-Mother had diabetes mellitus type 2 and died from diabetes complication at 81

-Father had chronic hypertension and died at the age of 78 from a stroke

-Patient does not recall the medical history of grandparents

-Denies any noted illness for his siblings and children.

Lifestyle: Mr. Cortez runs a small family construction business, which he runs with his son. He is a Christian and attends church with his family every Sunday. The highest level of education is high school with certifications in HVAC and plumbing. He lives at home with his wife, daughter, who is a single mother and grandson. His wife works full time as a secretary, and his health coverage is through his wife’s job. He states he is too busy to exercise, and his diet comprises mainly of heavy meals due to his job. Reports drinking socially, about 2-3 drinks weekly, mostly beer. Never smoked, denies the use of recreational or illicit drugs

Review of Systems

General: Mr. Cortez appears well dressed and well-nourished. Denies weakness and fatigue. No recent weight changes or changes in appetite. No apparent signs of distress.

HEENT: The patient uses glasses, denies vision changes, discharge from eyes, tinnitus, hearing loss, and discharge from ears. Denies loss or decreased sense of smell, nasal drainage, or congestion.

Neck: The patient denies any injury to the neck, swelling, or history of compression. Rash currently present in the neck region.

Breasts: denies lump, discharge, or rash

Respiratory: denies shortness of breath, denies cough or respiratory distress, no history of respiratory disorders except occasional seasonal allergies

Cardiovascular/Peripheral Vascular: Denies chest pain, reports history of hypertension and high cholesterol. He denies history of stroke, edema or heart failure.

Gastrointestinal: Denies nausea or vomiting, and diarrhea. Reports consistent bowel movement every two days. He also reported that his wife occasionally gives him prune juice to aid his occasional constipation.

Genitourinary: Pt denies any feeling of urgency or urinary retention. No history of UTI or incontinence denies burning sensation when urinating, denies frequency, and urgency.

Musculoskeletal: The patient reported a history of fall six months ago when he woke up and could not find his cane at the bedside. The patient stated that he takes 30 mins to walk in the evenings three times per week with his wife.

Psychiatric: The patient denies any history of mental illness, no suicidal or homicidal ideations. Reports no history of mental illness in his family.

Neurological: The patient reported feeling lightheaded after his fall 6 months ago but was seen by the ER doctor and has not had any dizziness episodes since then. Denies any headaches or sudden/abnormal movements.

Skin: The patient reports a red rash with blisters filled with clear fluid on his right torso and neck. Patient denies any other skin issues, a history of chickenpox when he was eight years old

Hematologic: Denies any abnormal bleeding. Denies any history of bleeding disorder in his family. Never been diagnosed with anemia, no history of incidents with significant blood loss.

Endocrine: Denies any use of hormonal therapies, denies a history of thyroid disorders.

Allergic/Immunologic: Patient denies any history of allergies, reported that he and his children often have seasonal allergies but usually resolves within a few days

OBJECTIVE DATA:

Physical Exam:

Vital signs:

– Blood Pressure: 148/93 mmHg -Weight.: 285 lbs

– Pulse: 76 BPM -Height: 170 cm

– Respiratory Rate: 18 – Blood glucose: 148 mg/dl

– Temperature: 98.9 F

General: The patient is alert and oriented, able to communicate clearly, posture, and gesture appropriately, maintains eye contact. Well dressed and groomed, appropriate affect, and reaction. Ambulates independently, gait even and steady

HEENT: Head, Face is symmetrical, bilateral eyes, ears, and nose symmetrical. No drainage or foul odor noted, no discoloration noted.

Neck: No swelling or deviation was noted. No Jugular Vein Distention noted that the carotid artery is palpable bilaterally, rash noted on the right side, and able to move from side to side.

Chest: Equal rise and fall of chest noted. Clear to auscultation Anterior, Posterior and Lateral

Lungs: Lung sounds clear, bilaterally anteriorly, posteriorly, and laterally. The respiratory pattern regular, the chest wall is symmetrical, no cough is noted.

Heart: No murmurs or palpitations noted

Peripheral Vascular: symmetrical, No edema or discoloration noted in extremities, Pulse regular 2+ pulse in the bilateral pedal, and 2+ in bilateral radial.

Abdomen:  Abdomen soft, flat, and non-tender, no distention noted, no organomegaly noted.

Genital/Rectal: External genitalia intact, no swelling or discoloration noted

Musculoskeletal: Uneven gait noted; the patient uses a cane for balance.

Neurological:  Alert and oriented to person, place, time, and situation. CN I – XII intact

Skin: Patients’ skin is generally warm, intact, and dry. Red raised vesicles with clear fluids on the right chest, underarms, neck, and back. Site warm to touch. No other skin abnormality was noted.

Clinical Terminology for Skin Condition in Graphic five

The skin condition in graphic five presents as a rash, which is red in color. The rash is present on the right lateral side of the patient’s chest and back. Some of the rashes are fluid-filled and appears blistering.

Differential Diagnosis

Contact Dermatitis: Contact dermatitis is a common skin disorder that occurs after exposure to allergens or irritants (World, Allergy Organization, 2015). Irritants such as soaps, detergents, stool, and urine trigger irritant contact dermatitis while cosmetics, drugs, food, or dye in people genetically predisposed or sensitized triggers allergic contact dermatitis.

The skin condition is characterized by red vesicles that are itchy (World, Allergy Organization, 2015). The location of the rash depends on the exposure to allergens. It is often diagnosed with history and physical (American Academy of Allergy Asthma & Immunology, 2019).

Psoriasis: Psoriasis is an autoimmune skin condition characterized by dry, red, and scaly rash (Nair & Badri, 2018). There are different types of psoriasis, however, psoriasis in general, is often seen with red scales covered with silver scales (Nair & Badri, 2018). The exact etiology of psoriasis is unknown; however, it has been seen to be genetically transmitted (Nair & Badri, 2020). the rash can appear anywhere in the body, including the eyes and scalp; it is also commonly seen in the knees and elbows; thus, the rash location and progression are often used when diagnosing the condition (Nair & Badri, 2020).

Shingles: Shingles is a skin condition also called Herpes Zoster caused by the varicella-zoster virus; it usually occurs in a patient who has previously had chickenpox virus or people older people with weakened immunity. The shingles rash are blistering red vesicles that usually appear in the face and torso (Carter, 2020). The rash may be itchy and painful with a burning or stinging sensation. It commonly affects one side of the body. It is usually diagnosed by the characteristics of the rash (National Institute of Neurological Disorders and Stroke, 2020).

Most Likely Diagnosis

Like many other conditions, diagnosing skin conditions starts with a good assessment, history, and physical (Ball, 2019). Assessment of Certain criteria is critical in helping a provider diagnose a skin disorder. For example, location, color, shape, measurement, surrounding skin, and texture of skin disorders will provide insight and help with accurate diagnosis (Ball, 2019). Other presenting symptoms, including systemic symptoms, are also used to identify and diagnose skin conditions (Ball, 2019). When collecting history and physical for skin conditions, it is important to collect a focused history that helps in diagnosing the skin conditions for example, the onset of skin condition, changes, presence of itch or discharge are some of the histories that help to diagnose skin conditions (Ball, 2019). Diagnostic tests can also help providers rule out certain conditions when diagnosing skin disorders. For example, shingles can be identified by testing for herpes or varicella-zoster virus. (Centers for Disease Control and Prevention, 2019).

The skin condition presented in this graphic is seen on the torso’s right lateral side; the rash appears to be red, fluid-filled, and blistering. Mr. Cortez states that the rash began about a week ago and is present only on his right side; he denies change in routine or exposure to irritants that could suggest allergic or irritant contact dermatitis. Also, the rash seen in contact dermatitis is scaly (Dains et al., 2019). Psoriasis rash, in this case, is unlikely because while psoriasis rash is red, it is also scaly and often appears on the knees, elbows, lower back, and scalp (Roland, 2018). Also, psoriasis is characterized by unique systemic symptoms such as swollen and painful joints, which Mr. Cortez denies (Davis, 2020). Shingles are the most likely diagnosis in this case because the rash, in this case, is red vesicles clustered together, appears in a linear arrangement, and is located on the right side of the torso without crossing the midline. According to Carter (2020), shingles rash are red lesions that are usually unilateral. During history, Mr. Cortez denies systemic symptoms that may suggest psoriasis; he also denies history, suggesting contact dermatitis.

 

References

American Academy of Allergy Asthma & Immunology (2019). Contact dermatitis overview. Retrieved from https://www.aaaai.org/conditions-and-treatments/library/allergy-library/contact-dermatitis

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Carter, T. M. (2020). Shingles: Not Just a Rash. Journal for Nurse Practitioners, 16(2), 111–115.

https://doi-org.ezp.waldenulibrary.org/10.1016/j.nurpra.2019.10.013

Centers for Disease Control and Prevention (2019). Laboratory Testing for VZV. Retrieved from https://www.cdc.gov/shingles/lab-testing/index.html

Conceicao, V. (2018). Prevention and management of shingles and associated

complications. Journal of Community Nursing, 32(6), 40–43.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and

clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Nair, P. A. & Badri, T. (2020). Psoriasis. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK448194/

National Institute of Neurological Disorders and Stroke (2020). Shingles Information Page. Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Shingles-Information-Page

Roland, J. (2018). Shingles vs. psoriasis: What’s the difference? Retrieved from  https://www.healthline.com/health/psoriasis/shingles-vs-psoriasis#symptoms

World, Allergy Organization (2015). Contact dermatitis: Synopsis. Retrieved from https://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/contact-dermatitis-synopsis

 

 

Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

  • Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
  • Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
  • Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
  • Consider which of the conditions is most likely to be the correct diagnosis, and why.
  • Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
  • Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
  • Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

The Lab Assignment

  • Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
  • Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
By Day 7 of Week 4

Submit your Lab Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK4Assgn1+last name+first initial.(extension)” as the name.
  • Click the Week 4 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 4 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK4Assgn1+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.
Excellent Good Fair Poor
Using the SOAP (Subjective, Objective, Assessment, and Plan) note format:
·  Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). ·   Use clinical terminologies to explain the physical characteristics featured in the graphic.
30 (30%) – 35 (35%)
The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.
24 (24%) – 29 (29%)
The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.
18 (18%) – 23 (23%)
The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.
(0%) – 17 (17%)
The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.
·   Formulate a different diagnosis of three to five possible considerations for the skin graphic.    ·   Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
45 (45%) – 50 (50%)
The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
39 (39%) – 44 (44%)
The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.
33 (33%) – 38 (38%)
The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.
(0%) – 32 (32%)
The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
(5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
(4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
(3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
(0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
(5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
(4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
(3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
(0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
(5%) – 5 (5%)
Uses correct APA format with no errors.
(4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
(3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
(0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100
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