Health assessent
Review the Skin Conditions document provided in this weeks 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 weeks Learning Resources to guide you as you prepare your SOAP note.Download the SOAP Template found in this weeks Learning Resources, and use this template to complete this Lab Assignment.The Lab AssignmentChoose 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 ofthree to fivepossible 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 weeks Learning Resources.
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the cold feels like it is descending into her chest. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago deferred admission RXd with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension well controlled
3.) Gastroesophageal reflux (GERD) quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating TAH 1998
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50s, healthy, living in nearby neighborhood.
Lifestyle:
She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.
Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.
Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR 1 month ago.
CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.
GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.
GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband.
MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.
Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.
Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.
Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endocrine: no endocrine symptoms or hormone therapies.
Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 52; BMI 21
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness diffuse no rebound
Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.
Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II XII grossly intact, DTRs intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
ASSESSMENT:
Lab Tests and Results:
CBC WBC 15,000 with + left shift
SAO2 98%
Diagnostics:
Lab:
Radiology:
CXR cardiomegaly with air trapping and increased AP diameter
ECG
Normal sinus rhythm
Differential Diagnosis (DDx):
1.) Acute Bronchitis
2.) Pulmonary Embolis
3.) Lung Cancer
Diagnoses/Client Problems:
1.) COPD
2.) HTN, controlled
3.) Tobacco abuse 40 pack year history
4.) Allergy to sulfa drugs rash
5.) GERD quiet on no current medication
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
2019 Walden University Page 4 of 4
2019 Walden University Page 3 of 4 Week 4 Lab Assignment:
Differential Diagnosis for Skin Conditions
1:
2:
3.
4.
5.
Page of Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patients interests, ADLs and IADLs if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patients age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
2019 Walden University Page 2 of 3 Patient Initials: EG Age: 69 Gender: F
SUBJECTIVE DATA
Chief Complaint (CC): Small reddish growths on the skin.
History of Present Illness (HPI): Erica Georges is a 60-year-old African American woman with complaints of lesions that have appeared on her torso. She has had them for the past week, and they have suddenly developed. The growths are raised off the skin with the presence of red blood cells, which is responsible for the reddish appearance. The patient notes that the growths are not itchy nor painful, but the reddish looks scare her, hence the reason she has resorted to seeking medical attention. She has been using hydrocortisone ointment for the past three days without any significant change. The patient reports occasional headaches, dizziness, and insomnia, which are related to other medical conditions, which is hypertension. She is currently taking medicine for hypertension.
Medication:
Hydrocortisone 3x daily
Bisoprolol 2.5mg tab 1x daily
Allergy:
Isosorbide mononitrate-hives
Past Medical History (PMH):
Apart from the skin rash, the patient reports being in her usual state of health apart from the mild complications related to age and the hypertensive condition. She was diagnosed with hypertension five years ago and has been taking prescription medicine to manage the disease. She adheres to her medication schedule.
Past Surgical History (PSH):
Hip replacement surgery 2001
Sexual/Reproductive history:
Personal Social History:
Used to drink alcohol occasionally while on social occasions but stopped ten years ago. No history of illicit drug use. Has never smoked.
Immunization History:
Up to date with immunization. Influenza vaccine last November and Pneumococcal 2 years ago
Significant family history:
Has a brother who had eczema since childhood. Has a sister 50 years old who was diagnosed with diabetes two years ago. The mother died of hypertension-related complications, was diagnosed at age 40 and died at age 78. Father diagnosed with diabetes at age 46.
Lifestyle:
The patient is retired and lives with a 21-year-old granddaughter who works and studies at the same time; hence she is alone in the house most of the time. The husband is deceased, and children have families and live some distance from her home. She does gardening when she has strength. No safety issues reported. No recent travel. She has a homecare nurse who comes twice a week to check her vital signs to ensure that her high blood pressure is not out of control.
She does not observe a nutritional diet. She is overweight and recognizes that this put her at risk of developing several health complications including diabetes. There is a community center nearby that have resources for the elderly. She has insurance, which caters for her prescription medication and other health costs.
Review of Systems:
General: the patient denies any recent fever or body changes. She, however, reports occasional difficulty in sleeping
HEENT: No rash noted near the eyes. No history of eye problem. No reported ear infections. No discharge observed in the ear. No complaints of mouth pain, no sore throat issues, absence of any mucosa swelling. Patient denies nasal stuffiness, no recent history of sinus infection.
Neck: No injury, pain, or history of compression
Breasts: The patient reports no current abnormal mammograms, no report of changes in the breasts.
Respiratory: The patient reports no night sweats, coughs, or dyspenia
Cardiovascular/Peripheral Vascular: No reported chest discomfort, palpitations or history of murmur, no chest pains, denies edema
Gastrointestinal: The patient denies any nausea or vomiting, absence of abdominal pain, no changes in bladder pattern.
Genitourinary: The patient is heterosexual, no change in urinary tract pattern, no history of STD or HPV, the patient is currently not sexually active.
Musculoskeletal: The patient reports no joint inflammation or pain. No history of fractures
Psychiatric: No history of mental illness, suicidal history, or anxiety/depression issues, present occasional sleep disturbance but denies experience of any delusions.
Neurological: No issues with memory or change in thinking patterns, no dizziness, but occasional headaches
Integumentary/Heme/Lymph: Presence of rashes, but do not itch, no bruising, no history of transfusions, no history of skin cancer
Endocrine: No hormone therapies or presence of endocrine issues
Allergic/Immunologic: Has hx of allergy to Isosorbide mononitrate.
OBJECTIVE DATA
Physical Exam:
Vital signs: BP -137/72 and regular, BMI 33.9, Weight 106.kg (16st 11IB), Height 1.72 (58)
General: A&O x3, NAD, comfortable, neatly dressed, alert and conscious
HEENT: PERRLA, EOMI, oronasopharynx is clear, pupils reactive to light and equal
Neck: trachea midline
Chest/Lungs: lungs clear on auscultation, regular respirations
Heart: RRR without murmur, rub, or gallop; pulses+2 bilat pedal
Peripheral Vascular: Abdomen: Not assessed
Genital/Rectal: Absence of cervical motion tenderness, external genitalia intact
Musculoskeletal: Age-related atrophy, normal muscle movement,
Neurological: CN II-XII grossly intact, DTRs intact
Skin: Reddish lesions raised off the skin surface on the trunk of the body. In other parts of the body, the skin has no palpable nodes, no presence of edema.
ASSESSMENT
Lab Results: Blood test for antinuclear antibody
Presence of lupus
CBC WBC 7,500 cells/mcL
Hemoglobin 12.6 grams/dL
Diagnostics
Lab: positive outcomes with biopsy
Cherry angiomas
Skin biopsy : punch biopsy analyzed under a microscope
sharply bounded vascular proliferation
adnexal structures and collarette of the epithelium
Priority Diagnosis:
Cherry angiomas
Also known as the Campbell De Morgan spots are cherry red bumps that occur on the skin. They occur either as a single spot on the skin or a group of spots. Most common spot for occurrence is the trunk of the body and the arm. However, they can also occur in other parts of the body; for instance, in rare cases, they occur on the scalp (Kim, Park, & Ahn, 2009). The exact reason why they occur is not known, but they commonly manifest in people from age 30 years onwards. They could be due to broken blood vessels, which bleed under the skin causing the red spots. Other associated causes of cherry angiomas include allergic reactions, aging skin, sun damage, bruise, or certain drugs (Dains, Baumann, & Scheibel, 2016). The aging factor may be the best explanation to account for the occurrence of cherry angiomas since they tend to increase in number as one becomes old. In this diagnosis, age could be the likely cause of cherry angiomas in the patient. The red spots, unlike most skin rashes, are not itchy and even though they appear as though they can burst any time, the spots do not bleed (Watkins, 2013). In addition, they are not dangerous and thus, it is not a necessity to treat them. However, they can be removed using electrocautery, shaving, or using lasers.
Normally, the condition is diagnosed clinically, but for doubts, it can be confirmed using skin biopsy. In this case, scanning the punch of spot reveals a sharply bounded vascular proliferation. In addition, it is characterized by adnexal structures and collarette of the epithelium. It is also important to note that the skin benign changes or growths that occur in the case of cherry angioma do not have cancer cells.
Diagnosis /Client problem
1. Cherry angiomas
2.
3. Occasional headaches
4.
5. Dizziness
Differential diagnoses (DDx):
Acute Urticaria
Angiokeratoma of the Scrotum
Bacillary Angiomatosis
Cutaneous Melanoma
References
