Wk 4 Differential Diagnosis for Skin Conditions

Wk 4 Differential Diagnosis for Skin Conditions Wk 4 Differential Diagnosis for Skin Conditions Discussion: Differential Diagnosis for Skin Conditions 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 Discussion, 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. Wk 4 Differential Diagnosis for Skin Conditions Note: Your Discussion post should be in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style Discussion posting format. 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 . To prepare: Review the Skin Conditions document provided in this week’s Learning Resources, and select two conditions to closely examine for this Discussion. Consider the abnormal physical characteristics you observe in the graphics 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. BY DAY 3 Post a description of the two graphics you selected (identify each graphic by number). Use clinical terminologies to explain the physical characteristics featured in each graphic. Formulate a differential diagnosis of three to five possible conditions for each. Determine which is most likely to be the correct diagnosis, and explain your reasoning. Read a selection of your colleagues’ responses. ·Consider which of the conditions is most likely to be the correct diagnosis, and why. Post a 1 page paper APA formatYour Discussion post should be in the SOAP (Subjective, Objective, Assessment, and Plan) note format, 1.a description of the two graphics you selected (identify each graphic by number). (see sample skin conditions attached) 2.Use clinical terminologies to explain the physical characteristics featured in each graphic. 3.Formulate a differential diagnosis of three to five possible conditions for each. Wk 4 Differential Diagnosis for Skin Conditions 4.Determine which is most likely to be the correct diagnosis, and explain your reasoning. READINGS Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. oChapter 8, “Skin, Hair, and Nails” (pp. 114-165) 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. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS usw1_nurs_6512_comprehensivesoaptemplate__2_.doc usw1_nurs_6512_comprehensivesoapexemplar__1_.doc usw1_nurs_6512_comprehensivesoaptempla Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? 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: 1. 2. 3. 4. 5. 6. 7. Location Quality Quantity or severity Timing, including onset, duration, and frequency Setting in which it occurs Factors that have aggravated or relieved the symptom Associated manifestations 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. © 2014 Laureate Education, Inc. Page 1 of 4 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. Wk 4 Differential Diagnosis for Skin Conditions 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. © 2014 Laureate Education, Inc. Page 2 of 4 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. 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. Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines. 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 © 2014 Laureate Education, Inc. Page 3 of 4 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? © 2014 Laureate Education, Inc. Page 4 of 4 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): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night.Wk 4 Differential Diagnosis for Skin Conditions She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed 6.) Over-the-counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs – rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet, on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: © 2014 Laureate Education, Inc. Page 1 of 4 Heterosexual G1P1A0 Non-menstruating – TAH 1998 Personal/Social History: She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time. Significant Family History: Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood. Lifestyle: She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She 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; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing. Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said. © 2014 Laureate Education, Inc. Page 2 of 4 Breasts: No reports of breast changes.Wk 4 Differential Diagnosis for Skin Conditions No history of lesions, masses, or rashes. No history of abnormal mammograms. Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago. CV: No 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: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation. GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband. MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures. Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history. Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history. Integument/Heme/Lymph: No rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions. Endocrine: No endocrine symptoms or hormone therapies. Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago. OBJECTIVE DATA Physical Exam: Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21 © 2014 Laureate Education, Inc. Page 3 of 4 General: A&O x3, NAD, appears mildly uncomfortable HEENT: PERRLA, EOMI, oronasopharynx is clear Neck: Carotids no bruit, jvd or tmegally Chest/Lungs: CTA AP&L Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses. 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 ASSESSMENT: Lab Tests and Results: CBC – WBC 15,000 with + left shift SAO2 – 98% Diagnostics: Lab: Radiology: CXR – cardiomegaly with air trapping and increased AP diameter ECG Normal sinus rhythm Differential Diagnosis (DDx): 1.) Acute Bronchitis 2.) Pulmonary Embolis 3.) Lung Cancer Diagnoses/Client Problems: 1.) COPD 2.) HTN, controlled 3.) Tobacco abuse – 40-pack-a-year history 4.) Allergy to sulfa drugs – rash 5.) GERD – quiet, on no current medication PLAN: [This section is not required for the assignments in this course but will be required for future courses.] © 2014 Laureate Education, Inc. Page 4 of 4 Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. Wk 4 Differential Diagnosis for Skin Conditions O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? 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: 1. 2. 3. 4. 5. 6. 7. Location Quality Quantity or severity Timing, including onset, duration, and frequency Setting in which it occurs Factors that have aggravated or relieved the symptom Associated manifestations 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. © 2014 Laureate Education, Inc. Page 1 of 4 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. Wk 4 Differential Diagnosis for Skin Conditions Do not use “WNL” or “normal.” You must describe what you see. © 2014 Laureate Education, Inc. Page 2 of 4 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. 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. Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines. 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 © 2014 Laureate Education, Inc. Page 3 of 4 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? © 2014 Laureate Education, Inc. Page 4 of 4 … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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Wk 4 Differential Diagnosis for Skin Conditions

Wk 4 Differential Diagnosis for Skin Conditions Wk 4 Differential Diagnosis for Skin Conditions Discussion: Differential Diagnosis for Skin Conditions 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 Discussion, 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. Wk 4 Differential Diagnosis for Skin Conditions Note: Your Discussion post should be in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style Discussion posting format. 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 . To prepare: Review the Skin Conditions document provided in this week’s Learning Resources, and select two conditions to closely examine for this Discussion. Consider the abnormal physical characteristics you observe in the graphics 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. BY DAY 3 Post a description of the two graphics you selected (identify each graphic by number). Use clinical terminologies to explain the physical characteristics featured in each graphic. Formulate a differential diagnosis of three to five possible conditions for each. Determine which is most likely to be the correct diagnosis, and explain your reasoning. Read a selection of your colleagues’ responses. ·Consider which of the conditions is most likely to be the correct diagnosis, and why. Post a 1 page paper APA formatYour Discussion post should be in the SOAP (Subjective, Objective, Assessment, and Plan) note format, 1.a description of the two graphics you selected (identify each graphic by number). (see sample skin conditions attached) 2.Use clinical terminologies to explain the physical characteristics featured in each graphic. 3.Formulate a differential diagnosis of three to five possible conditions for each. Wk 4 Differential Diagnosis for Skin Conditions 4.Determine which is most likely to be the correct diagnosis, and explain your reasoning. READINGS Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. oChapter 8, “Skin, Hair, and Nails” (pp. 114-165) 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. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS usw1_nurs_6512_comprehensivesoaptemplate__2_.doc usw1_nurs_6512_comprehensivesoapexemplar__1_.doc usw1_nurs_6512_comprehensivesoaptempla Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? 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: 1. 2. 3. 4. 5. 6. 7. Location Quality Quantity or severity Timing, including onset, duration, and frequency Setting in which it occurs Factors that have aggravated or relieved the symptom Associated manifestations 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. © 2014 Laureate Education, Inc. Page 1 of 4 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. Wk 4 Differential Diagnosis for Skin Conditions 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. © 2014 Laureate Education, Inc. Page 2 of 4 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. 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. Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines. 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 © 2014 Laureate Education, Inc. Page 3 of 4 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? © 2014 Laureate Education, Inc. Page 4 of 4 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): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night.Wk 4 Differential Diagnosis for Skin Conditions She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed 6.) Over-the-counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs – rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet, on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: © 2014 Laureate Education, Inc. Page 1 of 4 Heterosexual G1P1A0 Non-menstruating – TAH 1998 Personal/Social History: She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time. Significant Family History: Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood. Lifestyle: She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She 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; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing. Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said. © 2014 Laureate Education, Inc. Page 2 of 4 Breasts: No reports of breast changes.Wk 4 Differential Diagnosis for Skin Conditions No history of lesions, masses, or rashes. No history of abnormal mammograms. Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago. CV: No 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: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation. GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband. MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures. Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history. Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history. Integument/Heme/Lymph: No rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions. Endocrine: No endocrine symptoms or hormone therapies. Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago. OBJECTIVE DATA Physical Exam: Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21 © 2014 Laureate Education, Inc. Page 3 of 4 General: A&O x3, NAD, appears mildly uncomfortable HEENT: PERRLA, EOMI, oronasopharynx is clear Neck: Carotids no bruit, jvd or tmegally Chest/Lungs: CTA AP&L Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses. 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 ASSESSMENT: Lab Tests and Results: CBC – WBC 15,000 with + left shift SAO2 – 98% Diagnostics: Lab: Radiology: CXR – cardiomegaly with air trapping and increased AP diameter ECG Normal sinus rhythm Differential Diagnosis (DDx): 1.) Acute Bronchitis 2.) Pulmonary Embolis 3.) Lung Cancer Diagnoses/Client Problems: 1.) COPD 2.) HTN, controlled 3.) Tobacco abuse – 40-pack-a-year history 4.) Allergy to sulfa drugs – rash 5.) GERD – quiet, on no current medication PLAN: [This section is not required for the assignments in this course but will be required for future courses.] © 2014 Laureate Education, Inc. Page 4 of 4 Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. Wk 4 Differential Diagnosis for Skin Conditions O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? 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: 1. 2. 3. 4. 5. 6. 7. Location Quality Quantity or severity Timing, including onset, duration, and frequency Setting in which it occurs Factors that have aggravated or relieved the symptom Associated manifestations 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. © 2014 Laureate Education, Inc. Page 1 of 4 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. Wk 4 Differential Diagnosis for Skin Conditions Do not use “WNL” or “normal.” You must describe what you see. © 2014 Laureate Education, Inc. Page 2 of 4 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. 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. Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines. 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 © 2014 Laureate Education, Inc. Page 3 of 4 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? © 2014 Laureate Education, Inc. Page 4 of 4 … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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