NURS 6512 Skin Assessment SOAP Note 

NURS 6512 Skin Assessment SOAP Note

NURS 6512 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 three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment. Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies? Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected. Consider which of the conditions is most likely to be the correct diagnosis, and why. Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.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 (this means diagnoses related to skin conditions). 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.

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NURS6512 Skin Assessment SOAP Note

Patient Initials: Z. Y.             Age: 65                             Gender: Male

SUBJECTIVE DATA

Chief Complaint (CC): “I have several red raised lesions on my stomach and chest.”

Selected image #2.

History of Present Illness (HPI): The client, Z.Y, a 65yo, is a Caucasian male. He is presented to the clinic with red raised lesions on his stomach and chest. The client reports that the lesions are around 48 spots with rough and smooth edges and resemble little cherries. He reveals that the lesions started with about five spots two weeks ago and have been increasing gradually to about 48 spots. The client denies any aggravating or relieving factors.

Medications: No current medication.

Allergies: Denies food, drug, or environmental allergies.

Past Medical History (PMH): Denies any medical condition.

Past Surgical History (PSH): Denies any surgery.

Sexual/Reproductive History: N/A

Personal/Social History: Sedentary lifestyle and a social drinker.

Immunization History: Was immunized against pneumonia in October 2019.

Significant Family History:

Father: Was diagnosed with hypertension.

Mother: She has diabetes

Lifestyle: The client retired a few years ago. However, he receives unemployment checks.

ROS

 

General: Denies weight changes, fatigue, fever, or chills.

          HEENT: Denies head injuries, blurred vision, hearing, nasal congestion, or difficulty swallowing.

Neck: Denies any swelling.

 Breasts: Denies masses.

 Respiratory: Denies breathing difficulty.

Cardiovascular/Peripheral Vascular: Denies shortness of breath.

Gastrointestinal: Denies nausea and vomiting.

 Genitourinary: Denies blood in the urine.

 Musculoskeletal: Denies back pain.

  Psychiatric: Denies muscle stiffness.  

  Neurological: Denies dizziness.

Skin: Reports about 48 red and rough lesions that are slightly raised with sharp edges on the torso.

Hematologic: Denies anemia

Endocrine: Denies heat or cold intolerance.

Allergic/Immunologic: Denies food, drug, or environmental allergies.

OBJECTIVE DATA:

Physical Exam

Vital signs: T 97.9*F; B/P-119/67; HR-91 bpm; RR 18; Pulse Ox 95%; W 190lbs;  H 6’2″ and BMI score of 24.5.

General: The client, a 65yo, is a Caucasian male. He is well-nourished, well-groomed, appropriately dressed, and presentable. The client is alert and oriented to places, events, times, situations, and events. He sits upright and maintains eye contact throughout the interview. His affect is good, and he is future-oriented. He does not appear to be in mild distress.

HEENT:

            Head: No deformities to the scalp.

            Eyes: Equally round pupils that are sensitive to light

            Ear: Symmetrical bilaterally.

            Nose: No nasal drainage

            Throat: Moist and pink oral mucosa.

Neck: No lymphadenopathy noted.

Chest/Lungs: No wheezing sound.

Heart/Peripheral Vascular: No murmurs.

Abdomen: Bowel sounds are heard in the four quadrants.

Genital/Rectal: No blood was seen in the urine.

Musculoskeletal: Normal motor strength noted

Neurological: Strength was detected on all four extremities.

Skin: Approximately 48 red, rough, and raised lesions with sharp edges spreading throughout the stomach and chest. The size of the lesions ranges from 0.5 to 1mm. No bleeding or exudates was seen.

ASSESSMENT

Differential Diagnosis

            Based on subjective data and physical examination, the client’s potential diagnoses are as follows, prioritizing the most likely diagnosis.

1. Cherry Angiomas – Primary diagnosis
2. Angiokeratoma,
3. Pyogenic granuloma
4. Nodular basal cell carcinoma

Cherry angioma is the primary diagnosis for this client. This skin condition is characterized by a bright cherry red growth flat or raised on the skin, which occurs in different sizes (Nazer et al., 2020). This condition qualifies as the primary diagnosis since the client reports approximately 48 red, rough, and raised lesions with sharp edges spreading over the stomach and chest. Another potential diagnosis is Angiokeratoma, which is a wart-like red to black skin lesion common in older people (Arif, 2018). The color, shape, and sizes of Angiokeratomas are different. However, this condition is ruled out since Angiokeratomas tend to bleed and increase in size (Cohen & Celano, 2020). Thirdly, the client might be diagnosed with pyogenic granuloma. This skin condition is usually characterized by a small red, bleeding, or oozing skin bump (Wollina et al., 2017). However, this condition is ruled out due to the absence of bleeding or oozing, which is a significant feature (Parajuli & Maharjan, 2018). The last potential diagnosis for this client is Nodular basal cell carcinoma, characterized by exophytic pearl-shaped and raised nodules, which have telangiectasia on their surface.

References

Arif, T. (2018). Angiokeratoma of Fordyce associated with bilateral varicocele: look beyond the skin. J Dermat Cosmetol, 2(3), 168-170. DOI:10.15406/jdc.2018.02.00067.

Cohen, P. R., & Celano, N. J. (2020). Penile angiokeratomas (PEAKERs) revisited: A comprehensive review. Dermatology and Therapy, 10(4), 551-567. https://link.springer.com/article/10.1007/s13555-020-00399-3

Nazer, R. I., Bashihab, R. H., Al-Madani, W. H., Omair, A. A., & AlJasser, M. I. (2020). Cherry angioma: A case-control study. Journal of Family & Community Medicine, 27(2), 109. DOI: 10.4103/jfcm.JFCM_293_19

Parajuli, R., & Maharjan, S. (2018). Unusual presentation of oral pyogenic granulomas: a review of two cases. Clinical case reports, 6(4), 690. http://www.medtextpublications.com/open-access/pyogenic-granuloma-pg-common-lesion-at-uncommon-site-170.pdf

Wollina, U., Langner, D., França, K., Gianfaldoni, S., Lotti, T., & Tchernev, G. (2017). Pyogenic granuloma–a common benign vascular tumor with variable clinical presentation: new findings and treatment options. Open access Macedonian journal of medical sciences, 5(4), 423. Doi: 10.3889/oamjms.2017.111.