NURS-6512 Differential Diagnosis for Skin Conditions SOAP note

 LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

Week 4 Lab Assignment   

This week you will be submitting your paper in SOAP format.  The template and the grading rubric for this format is located in the Course Info folder.  This is the format approved for this course, so please follow it.  You will be choosing one skin graphic to write your SOAP note….you will go to the Word Document titled Skin Conditions under the week 4 Learning Resources.  You will choose one of the 5 lesions in the required resources for this assignment. You will need to organize your data in this format.....and under "S" you will need to ask your questions...but obviously your patient cannot answer you.  So....under "S"....create the subjective info for this patent, including CC, HPI, Meds, Allergies, ROS, etc.......think about everything that you would need to know and ask to make a clinical decision.  The "O" is what the condition looks like.  This is the objective piece of the note.....you do not ask the patient questions here, it is just what you observe.    Be specific!!!  Describe the lesion ie:  size, location, characteristics, etc....  think of this as documenting directly in a patient's chart.  A/P are your list of differentials with rationale on why you chose those diagnosis.  You list them from most likely to least likely.

In most cases, you will need to "create" information for each section.....for example, create a health history or background of the condition, etc….  For this week, your "O" will be the description of the lesion that you chose.  You will then choose at least 3 differential diagnosis for this condition, starting with the most likely to least likely.  Support these differentials with scholarly references.
A common mistake that students make in writing SOAP notes is confusing the S and the O.  Remember....the S is what you ask the patient, and the O is only the exam portion of the exam and what you observe.

3. APA......for the most part, everyone is doing a great job with this.  If you are being deducted points, it is due to missing information, or inaccurate formatting of the information.  I know that Blackboard is not user friendly with indenting, etc.... so I am not deducting for those types of issues.  I have heard from some of you regarding how to site websites, etc...  If you have questions, please ask, but if not....please utilize the resources that I have outlined in the weekly updates.  We are utilizing the APA 7th edition ….The Purdue Writing Owl is a great FREE online APA resource.

Without trying to sound too harsh.....you are graduate students, working at the graduate level.  You will be faced with APA throughout this program, and hopefully beyond when you decide to publish.  Once you master it, it will come to you very easily!!!  I was in your shoes three year's ago......but now it is second nature to me when I am reviewing your discussions. 

OK....I think that is everything for this update.  Stay strong, and stay focused.....I am very impressed with the dialogue in the discussion boards.  Don't stress over Shadow Health.....you will do a fabulous job!!  Keep up the great work!

Have a great week 4!!!!!

 Nursing 6512 Comprehensive WK 4 SOAP Note

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.

 Required read and resources

• 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.). St. Louis, MO: Elsevier Mosby.

  • Chapter 9, “Skin, Hair, and Nails”
    This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.

• Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
  Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
  This section explains the procedural knowledge needed prior to performing various dermatological procedures.
  • Chapter 1, “Punch Biopsy Download Chapter 1, “Punch Biopsy”
  • Chapter 2, “Skin Biopsy”Download Chapter 2, “Skin Biopsy”
  • Chapter 10, “Nail Removal”Download Chapter 10, “Nail Removal”
  • Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”Download Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
  • Chapter 16, “Skin Tag (Acrochordon) Removal”Download Chapter 16, “Skin Tag (Acrochordon) Removal”
  • Chapter 22, “Suture Insertion”Download Chapter 22, “Suture Insertion”
  • Chapter 24, “Suture Removal”Download Chapter 24, “Suture Removal”
• 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.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
  • Chapter 28, “Rashes and Skin Lesions”Download Chapter 28, “Rashes and Skin Lesions”
    This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
    Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.
• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
  • Chapter 2, "The Comprehensive History and Physical Exam" (Previously read in Weeks 1 and 3)
• VisualDx. (2021). Clinical decision supportLinks to an external site.: For professionals. Retrieved July 16, 2021, from http://www.skinsight.com/professionals
  This interactive website allows you to explore skin conditions according to age, gender, and area of the body.
• Bonifant, H., & Holloway, S. (2019). A review of the effects of ageing on skin integrity and wound healingLinks to an external site.. British Journal of Community Nursing, 24(Sup3), S28–S33. https://doi.org/10.12968/bjcn.2019.24.sup3.s28
• Document: Skin Conditions Download Skin Conditions(Word document)
  This document contains images of different skin conditions. You will use this information in this week’s Discussion.
• Document: Comprehensive SOAP Exemplar Download Comprehensive SOAP Exemplar(Word document)
• Document: Comprehensive SOAP Template Download Comprehensive SOAP Template(Word document)

Also Read: SOAP NOTE Writing Services

 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 Comprehensive SOAP Exemplar

 

ORDER A CUSTOM-WRITTEN SOAP NOTE NOW

 

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): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10. 

Medications: 

1. Norvasc 10mg daily
2. Combivent 2 puffs every 6 hours as needed
3. Advair 500/50 daily
4. Singulair 10mg daily
5. Over the counter Tylenol 325mg as needed
6. Over the counter Benefiber
7. Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs - rash 

Cipro-headache

Past Medical History (PMH): 

1.) Asthma

2.) Hypertension 

3.) Osteopenia 

4.) Allergic rhinitis

5.) Prostate Cancer

Past Surgical History (PSH):

1. Cholecystectomy 1994
2. Prostatectomy 1986

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

He has never smoked 

Dipped tobacco for 25 years, no longer dipping

Denied ETOH or illicit drug use.

Immunization History:

Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna

Influenza Vaccination 10/3/2020

PNV 9/18/2018

Tdap 8/22/2017

Shingles 3/22/2016  

Significant Family History:

One sister – with diabetes, dx at age 65

One brother--with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.

Lifestyle: 

He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable. 

He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He 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; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.

Neck: Denies pain, injury, or history of disc disease or compression.. 

Breasts:. Denies history of lesions, masses or rashes. 

Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.

CV: denies 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: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.

GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.

MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures. 

Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history. 

Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.

Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions. 

Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.  

Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyromegally

Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial 

ABD:  nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound 

Genital/Rectal: pt declined for this exam

Musculoskeletal: symmetric muscle development - some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact 

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

Diagnostics/Lab Tests and Results: 

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Covid PCR-neg

Influenza- neg

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Spirometry- FEV1 65%

Assessment:

Differential Diagnosis (DDx):

1. Asthmatic exacerbation, moderate
2. Pulmonary Embolism
3. Lung Cancer

Primary Diagnoses:

1.) Asthmatic Exacerbation, moderate

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

• template to complete this Lab Assignment.

 SOAP NOTE Template

 Skin Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC): 

History of Present Illness (HPI): 

Medications: 

Allergies: 

Past Medical History (PMH):

Past Surgical History (PSH): 

Sexual/Reproductive History:

Personal/Social History: 

Health Maintenance: 

Immunization History:

Significant Family History: 

Review of Systems: 

General: 

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails: 

OBJECTIVE DATA: 

Physical Exam:

Vital signs: 

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular: 

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results: 

ASSESSMENT: 

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

The 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 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

NURS 6512 Week 4 Assignment 1 Rubric

 

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeUsing 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.	35 to >29.0 pts Excellent 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. 29 to >23.0 pts Good 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. 23 to >17.0 pts Fair 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. 17 to >0 pts Poor 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.	35 pts
This criterion is linked to a Learning Outcome·   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.	50 to >44.0 pts Excellent 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. 44 to >38.0 pts Good 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. 38 to >32.0 pts Fair 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. 32 to >0 pts Poor 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.	50 pts
This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts Excellent 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 to >3.0 pts Good 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 to >2.0 pts Fair 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. 2 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation	5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.	5 pts
This criterion is linked to a Learning OutcomeWritten 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 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) APA format errors. 3 to >2.0 pts Fair Contains several (3 or 4) APA format errors. 2 to >0 pts Poor Contains many (≥ 5) APA format errors.	5 pts
Total Points: 100