Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this 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.
Download the SOAP Template found in this week’s Learning Resources.

To complete:

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 3 different references from current evidence based literature.  Comprehensive SOAP Template Essay Paper

Differential Diagnosis for Skin Conditions

SUBJECTIVE DATA

Chief Complaint (CC): Rashes and scaly plaques on the face and the scalp

History of Present Illness (HPI): AB a 27 year old female presented with well-defined erythematous scaly annular plaques that were scattered all over the face and scalp. AB has had psoriasis for the past 4 years and she was seeing a GP who prescribed oral and topical steroids. However, the client reported that there was no notable improvement after using the steroids. After treatment using the oral and topical steroids without any improvement, she was referred to a dermatologist. The dermatologist prescribed various topical therapists that consisted of Donovex ointment, UV phototherapy, as well as a synthetic Vitamin D3 derivative. However, after using the prescribed treatment for several months, she continued to experience severe psoriasis flare up.  She is currently on topical Anthralin (dithranol) and UV phototherapy.  Comprehensive SOAP Template Essay Paper

 Medications:

• Oral and topical steroids
• Donovex ointment
• UV phototherapy
• Synthetic Vitamin D3 derivative
• Anthralin (dithranol

Allergies:

• Dust mites
• Mold counts

Past Medical History (PMH):

• Asthma
• Lesions flare up on skin
• Rashes

Past Surgical History (PSH):

• Nil

Sexual/Reproductive History:

• Nil

Personal/Social History

• Non smoker
• No alcohol or substance abuse
• Works as an environmental engineer

Immunization History:

• All the patient’s immunizations up to date; her last pneumococcal vaccination was in 2014. The patient gets influenza vaccination annually

Family History:

• Father- high blood pressure on treatment
• Mother- history of arthritis
• Sister one had a psoriasis flare up

Lifestyle:

Patient AB lives with her boyfriend. She is an environmental engineer by profession and during field work she gets significant sunlight exposure, although she always wears sunscreen. Her family is stable financially and they own a home in one of the high-end estates. She is very active physically and very keen on her diet. She has adopted a vegetarian diet. She reports that she likes trying out different types of creams, especially for her face and she is a fun of makeups.

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REVIEW OF SYSTEMS:

General: Patient XX stated she has been in good health generally, apart from skin rashes and psoriasis that has persisted for the last 4 years. No significant weight loss/gain reported. Scattered erythematous plaques on the face and scalp

HEENT: No reported headache or vision change. No facial abnormality or sinus tenderness. Assessment of conjunctivae and oropharynx indicates they are very clear and normal. Normal tonsils and adequately moist mucous membranes. No swallowing difficulties and no report of sore throat. No dental problems and the patient reports that she attends dental check up every year.

Neck: The neck’s movement is okay and no notable stiffness. On evaluating the neck’s lymph nodes, there is no notable tenderness or lymphadenopathy. No abnormality with the thyroid gland. No bruits.

Breasts: No lump or masses. No pain or any nipple discharge.

Respiratory: The chest is clear. Examination of the lungs indicates a normal chest expansion. On auscultation, there is lung clearance and normal air movement.

Cardiovascular: Normotensive, regular normal pulse rate. No added heart sounds. No palpitations. No history of heart disease or hypertension.

Gastrointestinal: No abnormal bowel sound or abdominal distention. No difficulties or pain during swallowing. Patient’s appetite is normal and no complaints about heartburn or constipation. Normal stool and no rectal bleeding.

GU: The patient is sexually active and has a normal urinary pattern. No history of sexually transmitted infection. Normal genitalia. Has never given birth. No vaginal discharge. Last menstrual on 8/12/2018.

Musculoskeletal: No history of backache or fracture. No tenderness, no swellings, no effusions.  Normal range of motion for all joints. No joint deformities. The patient does not have any history of musculoskeletal disease.

Neurological: Awake. No reported dizziness. The patient is oriented both to time and place. Normal level of consciousness. The patient is cooperative. Tone, reflexes and sensation intact and within the normal limits in terms of functioning. Sensory and motor senses both normal.  Comprehensive SOAP Template Essay Paper

Psychiatric: Sleep disturbances, low self-esteem and poor self-image which are all associated to the skin rashes and flare up that makes her think she is no longer beautiful. No history of any mental disorder.

Endocrine: Normal urination pattern. Sweating is normal.

Skin: Scaled skin. Scattered erythematous indurated plagues on the face and scalp, with silver scaling. The plagues are irregular in shape. Positive Auspitz sign as indicated by capillary bleeding that occurs following the removal of overlying scale. Flexural involvement. Numerous lesions and plagues at the back of the neck appears tumor-like

Allergic/Immunologic: The patient is allergic to dust mites and mold counts

OBJECTIVE DATA

Physical Examination

Vital Signs: Temperature, afebrile: Heart rate 80: Blood pressure, 132/76; Respiratory rate, 16

General: Ambulatory female, awake, alert, oriented to both place and time, and co- operative. Smartly dressed and appears to be in good health. Scattered erythematous plagues on the face and the scalp, with silvery scale. No edema or palpable lymph nodes.

HEENT: The face and scalp are plagued with scattered erythematous plagues. Nasal mucosa is normal and also normal conjunctiva. Clear and normal oronasopharynx

Neck: The neck moves easily, without any resistance or notable stiffness. No notable tenderness or lymphadenopathy on the lymph nodes. No abnormality with the thyroid gland. No bruits. No JVD.

Chest: The lungs are clear, normal lung expansion and normal air movement

Heart: Normal pulse rate, no added heart sounds or murmurs, no gallops

Genital/Rectal: Normal stool without any diarrhea. No recta mass. Cervix and vagina appear normal. Normal rectal sphincter tone

Musculoskeletal: No notable musculoskeletal symptoms after examination

Neurological: Patient is alert and oriented to both time and place. No dizziness. Normal reflexes

Skin: Scattered erythematous plagues on the face and the scalp, with silvery scale. The lesions are irregular in shape. The skin is scaled and has rashes as well

ASSESSMENT

Differential Diagnosis (DDx):

• Psoriasis
• Nummular dermatitis
• Eczema
• Mycoses Fungoides (MF)
• Seborrheic dermatitis

Diagnosis tests

• Examination of lipid levels: Findings indicated 15% of high-density lipoproteins. Family history of psoriasis indicative of psoriasis. Clinical presentation of the plagues: Silver, erythematous and well defined plagues on the face and scalp.
• Skin biopsy: Because of some tumor like and abnormal morphology of lesions at the back of the neck, a skin biopsy was done to rule out Mycoses Fungoides (MF). The skin biopsy confirmed that the patient’s diagnosis was psoriasis

Diagnosis:

• Psoriasis

Comprehensive SOAP Template

 This template is for a full history and physical. For this course include only areas that are related to the case.

 Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.  Comprehensive SOAP Template Essay Paper

L =location

O= onset

C= character

A= associated signs and symptoms

T= timing

E= exacerbating/relieving factors

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 (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

 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. Identify if it is an allergy or intolerance.

 Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.

 Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

 Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

 Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

 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 so 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: 

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- only in this course. Do not use “WNL” or “normal.” You must describe what you see.  Comprehensive SOAP Template Essay Paper

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 consciousness, and affect and reactions to people and things.

HEENT:

Neck:

Chest

Lungs:

Heart

Peripheral Vascular: Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.

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 ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. 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.

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

References

Chong H, Kopecki Z & Cowin A. (2013). Lifting the Silver Flakes: The Pathogenesis and Management of Chronic Plaque Psoriasis. Biomed Res Int. 1(2013).

Kelley N. (2015). Living with psoriasis: a patient case study. J Vis Commun Med. 38(3-4), 164-167.

Lakshi A & Robert H. (2018). Manifestations and Management of Difficult-to-Treat Psoriasis.Journal of the Dermatology Nurses’ Association. 10(4), 189-197.

Singh S, Young P & Armstrong AW (2017). An update on psoriasis and metabolic syndrome: A meta-analysis of observational studies. PLoS ONE. 12(7), e0181039.

Young M & Lakshi A. (2017). Psoriasis for the primary care practitioner. Journal of the American Association of Nurse Practitioners. 29(3), 157-178.  Comprehensive SOAP Template Essay Paper