Nursing Assignment Acers

NURS6512 SKin Assessment SOAP Note

NURS6512 SKin Assessment SOAP Note

NURS6512 SKin Assessment SOAP Note

  • 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. NURS6512 SKin Assessment SOAP Note

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Differential Diagnosis for Skin Conditions Example Soap Note

Patient Initials: BA                                        Age: 84                                                                        Gender: F

SUBJECTIVE DATA: Left axillary skin tag/growth pain. Chief Complaint (CC): Skin Condition Picture #4 History of Present Illness (HPI):

Mrs. Barbara Acosta is an 84-year old Caucasian female with COPD, A-Fib, non- melanoma skin cancers, and CHF with a left-sided pacemaker who came in today concerned about this new painful axilla growth. The patient stated approximately four weeks ago, she was in the shower and palpated a skin growth mass in her left axilla, and it was tender and hurting her. She reports no bleeding, but when it gets irritated, it becomes red and swollen. She stated she has been shaving the area due to the hair growth irritates the growth more. The growth also gets caught on her clothing and pulls it and causes pain. Denies any itching or dryness to the site or immediate area. The current pain level is 4/10, but states with her history of skin cancers, and she is highly anxious.

Medications:

  • Metoprolol Tartrate 100mg oral, 1 tab, PO, Daily
  • Isosorbide Mononitrate 30mg oral, extended-release, 1 tab, PO, QAM
  • Furosemide 20mg oral, 1 tab, PO, Daily
  • Montelukast 10mg oral, 1 tab, PO, QPM
  • Atorvastatin 20mg oral, 1 tab, PO, Daily
  • Famotidine 20mg oral, 1 tab, PO, Daily
  • Albuterol 90 mcg/inh, 1 puff, QID, PRN: for Wheezing
  • Eliquis 5mg oral, 1 tab, PO, BID

Allergies: No Know Drug Allergies, No known food allergies, No known latex allergies

Past Medical History (PMH): Of note patient has a pacemaker on the left side that is very close to the skin growth, and she has the pacemaker for a history of atrial fibrillation and CHF. The patient also has a history of chronic bronchitis and asthma. History of non-melanoma skin cancers.

Past Surgical History (PSH): Tonsillectomy 1941, Appendectomy 1947, Hysterectomy 1980, CABG 199, Pacemaker 2015.

Sexual/Reproductive History:

Heterosexual, Gravida 3, Para 3, Abortus 0, Postmenopausal, Age at menopause 45.

Personal/Social History: Quit smoking 1990. Smoked 20 years. Denies alcohol or substance use. Moderate sun exposure, she does use sunscreen.

Immunization History: Immunizations are up to date. Tdap was in 2012. Influenza vaccine November 2019. Pneumococcal vaccine received in 2016.

Significant Family History:

Mother-deceased at age 78 from breast cancer. Father-deceased at age 77 from hypertension.

Maternal grandfather- deceased at age 66, died from heart disease. Maternal grandmother- deceased at age 66, died from a stroke

Paternal grandfather- deceased at age 81, died from colon cancer. Paternal grandmother-deceased at age 78, died from a heart attack. Son- Living, No health issues, age 60

Daughter- Living, Asthma, age 58 Daughter- Living, hypertension, age 61

Sister- Living, Asthma, Heart Disease, age 86

Lifestyle: Mrs. Acosta has a technical trade school education; she is currently retired, formally employed as an administrative assistant (hospitality industry). She is presently married and lives with her husband. She has support at home from her husband, and her children live close by and are a good support system for Mrs. Acosta. She regularly goes to church and has a close church family as support as well. NURS6512 SKin Assessment SOAP Note

Review of Systems:

General: Alert and oriented, no acute distress

HEENT: Oropharynx clear, Oral mucosa is moist, No pharyngeal erythema.

Neck: Supple, Non-tender

Breast: Left axillary growth measuring 2cm X 2 cm. No palpable right or left breast mass.

Respiratory: Respirations are non-labored. Lungs are clear to auscultation. Breath sounds are equal.

CV: Normal rate, Regular rhythm, No murmur.

GI: Soft, non-tender, non-distended, positive bowel sounds GU: Denies urgency, frequency, nocturia, and incontinence. MS: Denies back or joint pain, has a full range of motion. PSYCH: Cooperative, appropriate mood, and affect.

NEURO: Alert and oriented X4

INTEGUMENT/HEME/LYMPH: Warm, dry, no rash, left axilla skin growth ENDOCRINE: No abnormalities, not on hormone replacement ALLERGIC/IMMUNOLOGIC: No known allergies, no recurrent fevers OBJECTIVE DATA-

PHYSICAL EXAM:

B/P: 141/82, left arm P: 69 BPM regular rate T: 97.7 DegF Oral

RR: 16 br/min- non labored

Sp02: 98% -Room air

Wt: 63.7 Kg

BMI: 26.86

Ht: 60.6 inches- standing height

General: Mrs. Acosta is in good health but does have some comorbidities. She is alert and oriented X4; her husband is with her and provides excellent support. She is dressed appropriately, follows instructions, and askes the right questions. Full activity level.

HEENT: Oropharynx clear, Normocephalic, Normal hearing, Oral mucosa moist.

Neck: Supple, Non-tender, No lymphadenopathy

Chest/Lungs: Lungs are clear to auscultation, Respirations are non-labored, breath sounds are equal, Symmetric chest wall expansion, No chest wall tenderness.

Heart/Peripheral Vascular: Normal rate, Regular rhythm, No murmur, No edema Abdomen: Soft, non-tender, Nondistended, normal bowel sounds, no organomegaly Musculoskeletal: Normal range of motion, Normal strength, No tenderness, No swelling Neurological: Alert, Orientated, No focal defects. NURS6512 SKin Assessment SOAP Note

Skin: Warm, Dry, Intact, No edema, No rash, Visual skin growth left axilla

ASSESSMENT:

DIFFERENTIAL DX:

  • Cutaneous Tag/Skin Tag (Acrochordon)
  • Squamous cell carcinoma of left axilla (history of multiple SCC)
  • Seborrheic Keratoses
  • Common warts

DIAGNOSIS/CLIENT PROBLEM:

Acrochordons, or skin tags, are papillomas that are frequently observed in the neck and axillae region of middle-aged and older people (Ball et al., 2019). The most likely diagnosis for Mrs. Acosta is acrochordon. We don’t want to rule out a Squamous cell carcinoma because Mrs. Acosta has a history of skin malignancies other than melanoma. Skin squamous cell carcinoma that is detected early can be easily treated (Goh, Howle, Hughes, & Veness, 2009). Any new alterations or unexpected skin growths must be reported (Goh et al., 2009). The skin growth on Mrs. Acosta is squishy, flesh-colored, and just 2 cm long. Skin tags are typically not unpleasant, although they can become irritating or itchy when touched or snagged on clothing (Colyar, 2015). In skin creases, skin tags frequently develop. Skin tags tend to grow in skin folds but can appear anywhere on the body (Hay et al., 2011).

NURS6512 SKin Assessment SOAP Note References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Colyar, M. R. (2015). Advanced practice nursing procedures.

Goh, A., Howle, J., Hughes, M., & Veness, M. J. (2009). Managing patients with cutaneous squamous cell carcinoma metastatic to the axilla or groin lymph nodes. Australasian Journal of Dermatology, 51(2), 113-117. doi:10.1111/j.1440-0960.2009.00576.x

Hay, R. A., Kadry, D., Zeid, O. A., Safoury, O. E., Fawzy, M., Amin, I., & Rashed, L. (2011). Skin tags, leptin, metabolic syndrome, and change of the lifestyle. Indian Journal of Dermatology, Venereology, and Leprology, 77(5), 577. doi:10.4103/0378-

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Comprehensive SOAP

 

Patient Initials: __JJ_____           Age: __54_____                          Gender: __M_____

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): Small, itchy, raised patches on lower back

History of Present Illness (HPI):  Jeremiah Jergens is a 54-year-old Caucasian male who presents today with a large cluster of thick, red, raised patches on his lower back.  Jeremiah first noticed the patches 4 years ago, a few days after he recovered from a strep throat infection.  He has associated symptoms of tenderness, itchiness and flaking of the patches. They often bleed when he accidently scratches off a patch.  He reported the he is “embarrassed by the look of it” and will not take his shirt off at the beach.  He has also noticed both his knees, joints in his fingers and back are very stiff in the mornings but lessens after walking and using his joints for a bit.  He has been using Tylenol to help with the joint pain and for the patches, he reports using Benadryl ointment for the itching.  Both provide minimal relief.  He rates his discomfort a 4/10 today but in mornings 7/10 due to the joint pain.

Medications:

  1. Over-the-counter Tylenol 500mg PO once daily in the morning
  2. Over-the-counter Benadryl Extra Strength topical ointment as needed
  3. Atenolol 75 mg PO twice daily
  4. Over-the-counter Aspirin 325 mg PO once daily
  5. Men’s Multivitamin once daily
  6. Epi-Pen as needed

 CONT …

Comprehensive SOAP Template – NURS6512 SKin Assessment SOAP Note 

 

Patient Initials: ZY             Age: 65                             Gender: Female

 

 

SUBJECTIVE DATA:

 “I have multiple red raised lesions all over my chest and stomach”. This happened about two weeks ago

 

Chief Complaint (CC): Multiple raised red spots all over torso (image #2).

 

History of Present Illness (HPI): A 65-year-old Caucasian male presents to the clinic with multiple red papule all over torso. The spots are red in color, some raised and some are flat to the skin. There are about 48 spots and they look like little cherries and have rough and smooth edges to it. It started about two weeks ago with 5 spots and gradually increased to about 48 spots. There are no relieving or aggravating factors.

You must include the 7 attributes of each principal symptom:

  1. Location
  2. Quality
  3. Quantity or severity
  4. Timing, including onset, duration, and frequency
  5. Setting in which it occurs
  6. Factors that have aggravated or relieved the symptom
  7. Associated manifestations

 

Medications: None

 

Allergies: NKA

 

Past Medical History (PMH): None

 

Past Surgical History (PSH): None

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

 

Personal/Social History: Use alcohol occasionally. Sedentary lifestyle

 

Immunization History: pneumonia vaccine 10/2019

 

Significant Family History: mother has a hx of diabetes and father has a hx of hypertension

 

Lifestyle: Retired and receiving unemployment checks

 

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. You do not need to do them all unless you are doing a total H&P. To 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: Red raised and slightly elevated lesion with distinct edges, about 48 lesions on torso.

          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. Do not use WNL or normal. You must describe what you see.

 

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 conscience, and affect and reactions to people and things.

HEENT:

Neck:

Chest/Lungs: Always include this in your PE.

Heart/Peripheral Vascular: Always include the heart in your PE.

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin: Multiple red raised skin lesions scattered all over torso approximately 48 lesions, round in shape and some flat to the skin with distinct edges in varying sizes are about 0.5-1mm. no exudates or bleeding noted.

 

ASSESSMENT: Diagnostic testing is not needed for this patient

Diagnosis: Cherry Angiomas

Differential Diagnosis: Angiokeratoma, Pyogenic granuloma and Nodular basal cell carcinoma

 

A cherry angioma is a small papular angioma. It is also called a senile angioma. (Oakley, 2017). They occur in virtually everyone older than 30 years and increase numerically with age (Ball et al., 2018). Cherry angiomas are not usually painful and spread everywhere on the body. “In their early, and smaller, stages they are typically maraschino cherry red, hence the name cherry angiomas. As they enlarge or become thrombosed, some lesions become darker red or even black in color” (MDedge Family Medicine, 2019). “Cherry angiomas do not require treatment. If treatment is desired for cosmetic purposes, they can be treated with electrocautery, cryosurgery, or laser” (MDedge Family Medicine, 2019).

“Angiokeratoma is a benign skin lesion, appearing more commonly in older individuals. Angiokeratomas can be described as wart-like, red to black papules. Angiokeratomas vary in color, size, and shape; however, they are usually dark red to black in color. They range in size from papule lesions (up to 5 millimeters in size) to small plaque lesions (6 millimeters or higher in size). When touched, angiokeratomas feel hard and cannot be blanched, or faded, by compressing them. They may have an uneven surface described as “pebbled” (aocd.org, n.d.).

It is most definitely not a pyogenic granuloma because “Pyogenic granuloma is a relatively common skin growth. It is usually a small red, oozing and bleeding bump that looks like raw hamburger meat. It often seems to follows a minor injury and grows rapidly over a period of a few weeks to an average size of a half an inch.” (aocd.org, n.d.).

“Nodular basal cell carcinoma comprises about 60-80% of the cases and occurs most often on the skin of the head. Clinically it is presented by elevated, exophytic pearl-shaped nodules with telangiectasie on the surface and periphery” (Dourmishev, Rusinova, & Botev, 2013). Knowing this, it is very obvious this is not the diagnosis for this patient. “The lesions with big sizes and the central necrosis are defined as ulcus rodens” (Dourmishev et al., 2013).

 

 

 

 

 

 

 

List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. 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

 

References

Bernhard, J. D. (1990). Auspitz sign is not sensitive or specific for psoriasis. Journal of               the American Academy of Dermatology, 22(6), 1079-1081. doi:10.1016/0190-    9622(90)70155-b

Gladman, D. D., Shuckett, R., Russell, M. L., Thorne, J. C., & Schachter, R. K. (1987).     Psoriatic arthritis (PSA) – An analysis of 220 patients. QJM: An International Journal of Medicine, 62(238-241), 127.           doi:10.1093/oxfordjournals.qjmed.a068085

Mcgonagle, D. (2009). Enthesitis: An autoinflammatory lesion linking nail and joint    involvement in psoriatic disease. Journal of the European Academy of           Dermatology and Venereology, 23(S1), 9-13. doi:10.1111/j.1468-          3083.2009.03363.x

Siannis, F., Farewell, V. T., Cook, R. J., Schentag, C. T., & Gladman, D. D. (2006).          Clinical and radiological damage in psoriatic arthritis. Annals of the Rheumatic         Diseases, 65(4), 478-81. doi:10.1136/ard.2005.039826

Differential Diagnosis for Skin Condition Sample 2

NURS 6512: Advanced Health Assessment June 26, 2020

SOAP NOTE

Differential Diagnosis for Skin Condition

Patient Initials: BA                                        Age: 84                                                                        Gender: F

SUBJECTIVE DATA: Left axillary skin tag/growth pain. Chief Complaint (CC): Skin Condition Picture #4 History of Present Illness (HPI):

Mrs. Barbara Acosta is an 84-year old Caucasian female with COPD, A-Fib, non- melanoma skin cancers, and CHF with a left-sided pacemaker who came in today concerned about this new painful axilla growth. The patient stated approximately four weeks ago, she was in the shower and palpated a skin growth mass in her left axilla, and it was tender and hurting her. She reports no bleeding, but when it gets irritated, it becomes red and swollen. She stated she has been shaving the area due to the hair growth irritates the growth more. The growth also gets caught on her clothing and pulls it and causes pain. Denies any itching or dryness to the site or immediate area. The current pain level is 4/10, but states with her history of skin cancers, and she is highly anxious.

Medications:

 

  • Metoprolol Tartrate 100mg oral, 1 tab, PO, Daily

 

  • Isosorbide Mononitrate 30mg oral, extended-release, 1 tab, PO, QAM

 

  • Furosemide 20mg oral, 1 tab, PO, Daily

 

  • Montelukast 10mg oral, 1 tab, PO, QPM

 

  • Atorvastatin 20mg oral, 1 tab, PO, Daily

 

  • Famotidine 20mg oral, 1 tab, PO, Daily

 

  • Albuterol 90 mcg/inh, 1 puff, QID, PRN: for Wheezing

 

  • Eliquis 5mg oral, 1 tab, PO, BID

 

Allergies: No Know Drug Allergies, No known food allergies, No known latex allergies

 

Past Medical History (PMH): Of note patient has a pacemaker on the left side that is very close to the skin growth, and she has the pacemaker for a history of atrial fibrillation and CHF. The patient also has a history of chronic bronchitis and asthma. History of non-melanoma skin cancers.

Past Surgical History (PSH): Tonsillectomy 1941, Appendectomy 1947, Hysterectomy 1980, CABG 199, Pacemaker 2015.

Sexual/Reproductive History:

 

Heterosexual, Gravida 3, Para 3, Abortus 0, Postmenopausal, Age at menopause 45.

 

Personal/Social History: Quit smoking 1990. Smoked 20 years. Denies alcohol or substance use. Moderate sun exposure, she does use sunscreen.

Immunization History: Immunizations are up to date. Tdap was in 2012. Influenza vaccine November 2019. Pneumococcal vaccine received in 2016.

Significant Family History:

 

Mother-deceased at age 78 from breast cancer. Father-deceased at age 77 from hypertension.

Maternal grandfather- deceased at age 66, died from heart disease. Maternal grandmother- deceased at age 66, died from a stroke

 

 

Paternal grandfather- deceased at age 81, died from colon cancer. Paternal grandmother-deceased at age 78, died from a heart attack. Son- Living, No health issues, age 60

Daughter- Living, Asthma, age 58 Daughter- Living, hypertension, age 61

Sister- Living, Asthma, Heart Disease, age 86

 

Lifestyle: Mrs. Acosta has a technical trade school education; she is currently retired, formally employed as an administrative assistant (hospitality industry). She is presently married and lives with her husband. She has support at home from her husband, and her children live close by and are a good support system for Mrs. Acosta. She regularly goes to church and has a close church family as support as well. NURS6512 SKin Assessment SOAP Note

Review of Systems:

 

General: Alert and oriented, no acute distress.

 

HEENT: Oropharynx clear, Oral mucosa is moist, No pharyngeal erythema.

 

Neck: Supple, Non-tender

 

Breast: Left axillary growth measuring 2cm X 2 cm. No palpable right or left breast mass.

 

Respiratory: Respirations are non-labored. Lungs are clear to auscultation. Breath sounds are equal.

CV: Normal rate, Regular rhythm, No murmur.

 

 

GI: Soft, non-tender, non-distended, positive bowel sounds GU: Denies urgency, frequency, nocturia, and incontinence. MS: Denies back or joint pain, has a full range of motion. PSYCH: Cooperative, appropriate mood, and affect.

NEURO: Alert and oriented X4

 

INTEGUMENT/HEME/LYMPH: Warm, dry, no rash, left axilla skin growth ENDOCRINE: No abnormalities, not on hormone replacement ALLERGIC/IMMUNOLOGIC: No known allergies, no recurrent fevers OBJECTIVE DATA-

PHYSICAL EXAM:

 

B/P: 141/82, left arm P: 69 BPM regular rate T: 97.7 DegF Oral

RR: 16 br/min- non labored

 

Sp02: 98% -Room air

 

Wt: 63.7 Kg

 

BMI: 26.86

 

Ht: 60.6 inches- standing height

 

 

 

 

 

 

General: Mrs. Acosta is in good health but does have some comorbidities. She is alert and oriented X4; her husband is with her and provides excellent support. She is dressed appropriately, follows instructions, and askes the right questions. Full activity level.

HEENT: Oropharynx clear, Normocephalic, Normal hearing, Oral mucosa moist.

 

Neck: Supple, Non-tender, No lymphadenopathy

 

Chest/Lungs: Lungs are clear to auscultation, Respirations are non-labored, breath sounds are equal, Symmetric chest wall expansion, No chest wall tenderness.

Heart/Peripheral Vascular: Normal rate, Regular rhythm, No murmur, No edema Abdomen: Soft, non-tender, Nondistended, normal bowel sounds, no organomegaly Musculoskeletal: Normal range of motion, Normal strength, No tenderness, No swelling Neurological: Alert, Orientated, No focal defects

Skin: Warm, Dry, Intact, No edema, No rash, Visual skin growth left axilla

 

ASSESSMENT:

 

DIFFERENTIAL DX:

 

  • Cutaneous Tag/Skin Tag (Acrochordon)

 

  • Squamous cell carcinoma of left axilla (history of multiple SCC)

 

  • Seborrheic Keratoses

 

  • Common warts

 

 

DIAGNOSIS/CLIENT PROBLEM:

 

Cutaneous tag/ skin tag (Acrochordon) are papillomas commonly found in the neck and axillae region of the middle-aged and elderly population (Ball et al., 2019). Acrochordon is the most likely diagnosis for Mrs. Acosta. Due to Mrs. Acosta’s history of non-melanoma skin cancers, we don’t want to rule out a Squamous cell carcinoma. Early detection of squamous cell carcinoma of the skin can be easily treated (Goh, Howle, Hughes, & Veness, 2009). It is essential to report any new changes or unusual skin growths (Goh et al., 2009). Mrs. Acosta’s skin growth is skin-colored, small 2cm, and fleshy. Skin tags are not traditionally painful but can be tender or irritated by touched or caught on clothing (Colyar, 2015). Skin tags tend to grow in skin folds but can appear anywhere on the body (Hay et al., 2011).

References – NURS6512 SKin Assessment SOAP Note

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Colyar, M. R. (2015). Advanced practice nursing procedures.

Goh, A., Howle, J., Hughes, M., & Veness, M. J. (2009). Managing patients with cutaneous squamous cell carcinoma metastatic to the axilla or groin lymph nodes. Australasian Journal of Dermatology, 51(2), 113-117. doi:10.1111/j.1440-0960.2009.00576.x

Hay, R. A., Kadry, D., Zeid, O. A., Safoury, O. E., Fawzy, M., Amin, I., & Rashed, L. (2011). Skin tags, leptin, metabolic syndrome, and change of the lifestyle. Indian Journal of Dermatology, Venereology, and Leprology, 77(5), 577. doi:10.4103/0378-6323.84061

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