Differential Diagnosis for Skin Conditions Assignment

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Differential Diagnosis for Skin Conditions Assignment

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:

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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. Differential Diagnosis for Skin Conditions Assignment

 

Medications:

  • Norvasc 10mg daily
  • Combivent 2 puffs every 6 hours as needed
  • Advair 500/50 daily
  • Singulair 10mg daily
  • Over the counter Tylenol 325mg as needed
  • Over the counter Benefiber
  • 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):

  • Cholecystectomy 1994
  • 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 Differential Diagnosis for Skin Conditions Assignment

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. Differential Diagnosis for Skin Conditions Assignment

 

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. Differential Diagnosis for Skin Conditions Assignment

 

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 Differential Diagnosis for Skin Conditions Assignment

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):

  • Asthmatic exacerbation, moderate
  • Pulmonary Embolism
  • 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.] Differential Diagnosis for Skin Conditions Assignment

Subjective

CC: “Rash with some blisters and scab on my back and chest.”

HPI: K.M, a 59-year-old Caucasian male, presented to the clinic unaccompanied with a chief complaint new cluster of rashes with blisters on his anterior right flank and posterior chest. He reported that these symptoms began 7 days ago but four days before then, the affected area were itchy and he could feel some pain which he rated 8/10. He also reported significant pain in his right ear, a minor headache, fatigue, and a burning feeling that intensified when exposed to light. The patient reported that the discomfort is sometimes so intense that he cannot sleep.  He reported taking over-the-counter pain relievers, particularly ibuprofen 200mg, but this had little benefit. Denies experiencing nausea, vomiting, or diarrhea.

Current Medication: Ibuprofen 200mg 2tabs PO TID for pain and Flomax 0.4 mg PO qDay, 30 minutes after meal for BPH.

Allergies: NKDFA

Immunization: up-to-date. He received his last influenza vaccine 23/7/22, Tdap 12/5/2018. Moderna Covid-19 Vaccine 23/4/2021.

PMH: Benign prostatic hyperplasia (BPH), well managed. Chicken pox at 12 years old.

PSHx: TURP in 2021.

Family history: no significant family history reported.

Sexual Hx: Heterosexual.

Social history: The patient is a retired teacher at a neighboring college. He has never smoked or consumed alcohol. He is married with 5 children. Do not exercise. Reported consuming healthy diet rich in fruits and vegetables.

ROS

General: reported fever, headache and general fatigue. Denies any significant changes in weight

HEENT:  Reported intense pain in the right ear. Denies vision or hearing problem.

Cardiovascular: denies chest pain, and palpitation

Respiratory: Denies SOB, cough and history of pneumonia.

GI: Denies nausea and vomiting.

GU: Denies dysuria or polyuria. No history of STDs reported

Psych: denies anxiety and depression. No suicidal ideation reported.

Msk: Denies joint or muscle pain. Differential Diagnosis for Skin Conditions Assignment

Neurologic: Denies dizziness and gait disturbances.

Skin: reported a cluster of painful rashes with blisters on the anterior and posterior part of the chest.  Denies changes in skin color.

Endocrine: Denies issue with heat or cold intolerances.

O.

PE

Vts.: T.37.1 oc. BP 124/80.  P 84.   R 20 Wt.: 56 Height: 5’4

General: A&Ox3, well-groomed, no acute distress noted.

HEENT; normocephalic and atraumatic., PERRLA, and EOMI

Cardiovascular: RRR, S1, S2 intensity are of normal, no murmur, nor gallops noted

Lungs: chest is symmetrical. Lung sounds equal and clear on auscultation.

MSK: muscle strength 5/5 bilaterally. No history of trauma or fractures.

Skin:  Appropriate color to ethnicity. Cluster with fluid-filled blister noted on the posterior chest and back.

Abdomen: Soft and non-tender. Bowel sounds are normoactive.

Neuro:  Memory and thought process intact. No abnormal sensory and stable gait noted.

Genital: normal rectal sphincter tone. Guac is negative.

Psychiatric: Appropriate mood and affect. Insight and judgement are good.

A.

Lab test and result

CBC: WBC 7,000, RBC 4.8 mcL

Polymerase chain reaction (PCR):  result pending

ELISA: positive IgM

Covid PCR-neg

Differential diagnoses

  1. Shingles

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This is a viral infection that affects a single sensory nerve ganglion and the skin regions it supplies. Shingles is characterized by discomfort, which is accompanied by a rash which evolves onto blisters that dries out to form scabs (Fritz et al.,2020). As demonstrated in the case presentation, it is also defined by headache, discomfort in the affected area, fever, and general fatigue. Furthermore, this illness affects specific parts of the body and does not cross the midline, making it a likely diagnosis. Differential Diagnosis for Skin Conditions Assignment

  1. Eczema

This is a skin infection that produces dryness, redness, itching, and bumpiness. Muscle tension, constipation, difficulty focusing, continual concern, pains, and dizziness are among symptoms of eczema (Szari et al.,2019).

  1. Contact Dermatitis

This is an inflammatory skin illness induced by chemicals or metal ions that are noxious without triggering a T-cell response. It is distinguished by an itchy rash, rough skin, and blisters (Aquino et al.,2019). It also shows signs of hyperpigmented skin, which were not seen in the case presentation.

Primary diagnoses: Shingles

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

 

 

References

Aquino, M., & Rosner, G. (2019). Systemic contact dermatitis. Clinical reviews in allergy & immunology, 56(1), 9-18. https://link.springer.com/article/10.1007/s12016-018-8686-z

Fritz, D. J., Curtis, M. P., & Kratzer, A. (2020). Shingles. Home Healthcare Now, 38(5), 282-283. https://journals.lww.com/homehealthcarenurseonline/Citation/2020/09000/Shingles.13.aspx

Szari, S., & Quinn, J. A. (2019). Supporting a healthy microbiome for the primary prevention of eczema. Clinical Reviews in Allergy & Immunology, 57(2), 286-293. https://link.springer.com/article/10.1007/s12016-019-08758-5

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.

*As far as the SOAP notes, you do not have enough information. I advise them to make up the information that is not there (ie. Health Hx, social Hx, etc). This will allow you to critically think as you develop the notes. *

Skin Condition 4 seems like it is cellulitis. Differential Diagnosis for Skin Conditions Assignment