Description
Skin condition: you will choose a picture from the images of skin conditions provided. Based on the diagram you chose, you will make up your chief complaint, history of present illness, review of systems, based on the diagram. Please make sure to follow the grading rubric for this assignment. I am including a soap template for the skin condition for you use to use. I You may use this as an example as a guide.
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 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.
Learning 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)
Criteria Ratings Pts
This criterion is linked to a Learning Outcome 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.
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
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Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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© 2021 Walden University
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): 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
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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.
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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:
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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.]
© 2021 Walden University
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Week 4
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:
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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.
© 2021 Walden University
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