SOAP Note For Advanced Health Assessment And Diagnostic Discussion

For this assignment there is a template attached to use. There is also a document of skin conditions for which you will pick one. 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.
To Prepare SOAP Note For Advanced Health Assessment And Diagnostic

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Discussion
• 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? SOAP Note For Advanced Health Assessment And Diagnostic Discussion
• 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 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. SOAP Note For Advanced Health Assessment And Diagnostic Discussion

SOAP Note

Skin condition image 5#

Patient information

Patient initials: P.T         Age: 58           Race: Hispanic       Gender: male

S.

CC:” Itching and burning rash with blisters.”

HPI:  P.T, a 58-year-old Hispanic male patient, presented to the clinic with a 7-day-old itchy and uncomfortable rash with blisters on his left upper chest and back. He reported that the discomfort, which he rated as a 7/10, is interfering with his regular activities. He reported using Ibuprofen 500mg to relieve discomfort, albeit it has very little effect. He denies having a headache, vomiting, or diarrhea, but claims that the discomfort worsens when it comes into contact with the clothing.

Medication: ibuprofen 500mg PO prn to manage pain and Glucophage XR PO to manage diabetes

Allergies: no known drug and food allergies

PMH: He has type 1 diabetes, which he is presently managing with Glucophage XR. He also recalled acquiring chicken pox when he was 17 years old.

Immunization: Up to date.  He received his Covid-19 vaccine on 19/7/2021 and influenza vaccine 4/6/2022

Past surgical history: no history was reported.

Family history: His mother (78-year-old): diabetes type 1. Father (deceased): lung cancer. Maternal grandfather (deceased): prostate cancer. His younger sister (35-year-old): hyperlipidaemia.  Elder brother (65 years-old):SOAP Note For Advanced Health Assessment And Diagnostic Discussion hypertension.

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Social history: The patient is a full-time lecturer at a local institution. He is married to a single lady who works as a nurse in a nearby private hospital, and they have four children who attend school far away from home. The patient denies smoking but admits to consuming alcohol once in a while with a companion. He reported enjoying school volleyball on occasion. He is financially secure, and his family’s health is covered by insurance. He stated that he does not use his phone while driving and that he frequently wears his seat belt for safety. Moreover, the patient reported eating a well-balanced diet high in fruits and vegetables. SOAP Note For Advanced Health Assessment And Diagnostic Discussion

ROS

General: No fevers, chills, or changes in weight reported.

HEENT: The patient denied any pain, redness, or vision issues. He claims he has no hearing loss, post-nasal drip, or nasal discharge.

Cardiovascular: He denied having chest discomfort, palpitation, an irregular heartbeat, cardiac murmurs, or paroxysmal nocturnal dyspnea.

Respiratory: The patient denies having chronic cough, SOB, and dyspnea on exertion.

GI: He denies vomiting, or experiencing diarrhea. He denies any change in bowel habits or heartburn.

GU: The patient denies any urinary hesitancy or dribbling. He denies nocturia and urine frequency. There were no reports of abnormal urethral discharge.

Msk: No myalgias or arthralgias. He reported having no history of trauma or orthopedic injuries. SOAP Note For Advanced Health Assessment And Diagnostic Discussion

Neurologic: Denies chronic headaches, seizures, and numbness in lower extremities.

Psychiatric: Denies having depression or anxiety or any suicidal ideation.

Endocrine: Denies heat or cold intolerances

Skin/lymph/heme: reported blisters of painful rashes on the chest and back areas.

O.

PE

VTS: BP 146/68 left arm, sitting using regular adult cuff. Wt.: 72 kg Ht. 5’6 T.: 36.1 RR: 18 P: 78 Sp02: 98%

General: The patient is attentive and oriented x3, well-nourished, and appears to be in no acute distress.

HEENT; normocephalic, EOMI, PERLA, hearing grossly intact, no nasal discharge, the patient teeth and gingiva in good condition.

Cardiovascular: SI and S2 are both normal. There are no murmurs. There were no carotid bruits. The extremities are warm and perfused.

Lungs: Clear to auscultation, rhonchi, no rales noted on percussion.

Skin: There are unilateral dark blood red, fluid-filled vesicles that are slightly warm to the touch on the upper chest and back noted.

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

MSK: ROM intact. Normal gait and posture.

Neuro: Cranial nerve ii to xii intact. Reflexes 2+, no abnormal sensation noted.

Psychiatric: He is oriented to place and time. Good judgement, no abnormal affect noted.

Assessment: SOAP Note For Advanced Health Assessment And Diagnostic Discussion

Lab test and result

CBC: results pending

PCR: To detect VZV on skin vesicles lesions.

Tzanck smear

Diagnosis

Differential diagnosis

Herpes zoster

Herpes zoster, also known as shingles, is a viral infection that results in a painful rash. The rash is typically unilateral and appears as a band of blisters on the chest or back (Dosi et al., 2021). The pain of herpes zoster can range from mild to severe, and the rash can scab over a period of 7 days to 10 to several weeks. Transmission is through direct contact with fluid from the rash blisters.

Herpes zoster is associated with a reactivation of the varicella-zoster virus, which is the same virus that causes chickenpox. This reactivation can occur anywhere on the body, but is more common on the chest and back (Kennedy et al., 2018). Hispanic individuals are at a higher risk for developing herpes zoster than other populations, owing to their increased susceptibility to the varicella-zoster virus. Based on the patient’s clinical presentation and the fact that he was once afflicted by chicken at the age of 17, this is the most likely diagnosis for him.

Herpes simplex virus

HSV is a viral infection characterized by tingling, burning and itching sensation which occurs before emergence of the sore. This infection is also associated with a painful rash that is characterized by the formation of blisters (Sanghera et al., 2018)SOAP Note For Advanced Health Assessment And Diagnostic Discussion. These blisters can occur on the skin or mucous membranes, and they may be filled with fluid. The blisters are typically found on the lips, mouth, or genitals, and can cause significant discomfort in those affected. In some cases, the blisters can also be found on other parts of the body. The virus is most commonly spread through sexual contact, but can also be spread through close contact with an infected person, such as through shared towels or clothing. Based on the patient’s complaint of a painful rash with blisters, this is a plausible diagnosis; however, the client did not report having tingling and burning feelings a day or two before the rash emerged.

Contact dermatitis

Contact dermatitis is a type of rash that is characterized by the development of blisters. This condition is often associated with pain and can be extremely uncomfortable. In severe cases, the blisters may burst and release a clear fluid. This fluid can then lead to the formation of scabs. Contact dermatitis often affects the hands, feet, and other areas of the body where skin is exposed (Li et al., 2021). It can also occur on the face, neck, and other areas where skin comes into contact with other objects. Contact dermatitis is most often caused by exposure to a substance or object that triggers the inflammation of the skin cells. This can happen when the skin is contaminated by bacteria, fungi, or other substances. The most common sources of contact dermatitis are cosmetics, soaps, detergents, and other irritants (Buckle, 2021)SOAP Note For Advanced Health Assessment And Diagnostic Discussion. Other causes include exposure to cigarette smoke, ultraviolet light, and chemicals.

Primary diagnoses: Herpes zoster virus

References

Buckley, D. (2021). Generalised Rashes in Adults. In Textbook of Primary Care Dermatology (pp. 161-174). Springer, Cham.

Dosi, T. R., Chawla, A. K., Barkalle, G., & Phulambrikar, T. (2021). Herpes zoster of orofacial region. Journal of Oral and Maxillofacial Pathology: JOMFP, 25(3), 557.

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Kennedy, P. G., & Gershon, A. A. (2018). Clinical features of varicella-zoster virus infection. Viruses, 10(11), 609.

Li, Y., & Li, L. (2021). Contact dermatitis: classifications and management. Clinical Reviews in Allergy & Immunology, 61(3), 245-281.

Sanghera, R., & Grewal, P. S. (2019). Dermatological symptom assessment. In Patient Assessment in Clinical Pharmacy (pp. 133-154). Springer, Cham SOAP Note For Advanced Health Assessment And Diagnostic Discussion