NURS-6512 Differential Diagnosis for Skin Conditions SOAP Note Template

NURS-6512 Differential Diagnosis for Skin Conditions SOAP Note Template

NURS-6512 Differential Diagnosis for Skin Conditions SOAP Note Template

Subjective

Patient:  Initials: N.S  

Age: 68 years

Sex- Male

Chief Complaint: “Painful knee joints.”

History of Present Illness: 

N.S is a 68-year-old male presenting with complaints of painful knee joints. He states that he began experiencing mild knee pain about 15 months ago after walking moderate to long distances. The pain advanced and started occurring when he walked, accompanied by stiffness that limited his movements. The severity of the joint pain has worsened over time from mild to moderate pain. He now experiences joint stiffness in the morning and during rest on some days. N.S describes the pain as deep and achy in both knee joints, lasting 10-15 minutes. The joint pain is aggravated by activities such as walking and alleviated to some degree by rest and Tylenol, but nothing relieves the joint stiffness. He denies using any other medication or measures to relieve the symptoms. He rates the pain at 5/10.

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Past Medical History: No history of medical illnesses.

Past Surgical History:  ORIF surgery at 43 years due to a Tibia fracture.

Medications:  OTC Motrin 400 mg to relieve joint pain.

Allergies: Allergic to Sulfur- causes a rash. No food or environmental allergies.

Immunizations:  Last TT shot-4 years ago. The last influenza shot- was three months ago. Fully vaccinated against COVID.

Family History:  The father had Diabetes and died at 76 years from renal failure. The mother has chronic asthma. The siblings and children are alive and well.

Social History/Risk Factors:  N.S is married and lives with his wife in Saunders County, NE. He has three children, 39, 35, and 29 years. The patient is a retired high school teacher and currently runs a supermarket, which generated enough profits to sustain him and his family in his retirement. He takes 2-3 glasses of whiskey on weekends and smokes 1PPD but denies using other illicit substances. His hobbies include watching football and writing articles.

Review of Systems:

General: Negative for appetite disturbances, weight changes, fever, chills, or generalized fatigue.

Head: Negative for headache, dizziness, or sinus pain.

Eyes: Negative for blurred/ double vision, visual changes,  eye redness, or excessive lacrimation. Last eye exam: 18 months ago.

Ears: Negative for changes or difficulty in hearing, ear pain, or drainage.

Nose: Negative for difficulty smelling, rhinorrhea, nasal congestion, or epistaxis.

Mouth/Throat: Negative for swallowing difficulties, difficulty eating/chewing foods, mouth sores or lesions, or sore throat. Last dental exam- was two years ago.

Neck: Denies neck pain, stiffness, or reflux.

Respiratory: Negative for SOB, dyspnea, cough, sputum, or wheezing.

Cardiovascular: Negative for palpitations, chest pain/pressure, or SOB with exertion.

GI: Negative for nausea, vomiting, heartburn, acid reflux, abdominal pain, hemorrhoids, rectal bleeding, constipation, or diarrhea.

GU: Negative for blood in urine, painful urination, urinary frequency, or urgency.

Musculoskeletal: Positive for bilateral knee joint pain and stiffness; Limitations in movement. History of a tibia fracture. Negative for muscle pain and low back pain.  

Neurological: Negative for muscle weakness, dizziness, unsteady gait, memory changes, or mood changes.

Psychiatric: Negative for depression, anxiety, sleep disturbances, suicidal ideations/ attempts.

Skin: Negative for discoloration, rashes, or lesions.

Endocrine: Negative for weight loss/ weight gain, excessive lacrimation, hair thinning/loss, heat or cold intolerance, excessive thirst, or hunger.

Hem/Lymph: Negative for bruising, excessive healing time, or anemia.

Objective

Vital Signs: Temp-98.96; BP- 132/80; HR-78; RR-16; SPO2-99%

Height- 5’5 Weight- 189, BMI-31.4

General: AA male in his late 60s. The patient is well-groomed and appropriately dressed for the weather and event. He is alert and in no distress, and maintains adequate eye contact. He is oriented to person, place, and time. His thought process is logical and goal-oriented, and his speech is clear.

HEENT:  Head is symmetrical and atraumatic. Eyes: Sclera is white; Conjunctiva is pink; PERRLA. Ears: TMs are shiny and intact bilaterally; Minimal pus. Nose: Pink nasal mucosa; Nasal septum well-aligned. Throat: Pink and wet mucous membranes; Tonsillar is non-inflamed and non-erythematous.    

Neck: Symmetrical, trachea is midline, and the thyroid gland is normal on palpation.

Lymph Nodes: Lymph nodes are non-palpable.

Respiratory:  Smooth respiratory movements with uniform chest rise and fall. The chest is clear on auscultation.

Cardiovascular:  No edema or neck vein distension. Regular heart rate and rhythm; S1 and S2 present; No systolic murmurs.

GI: Normoactive bowel sounds in all quadrants. No organomegaly, abdominal masses, guarding, or tenderness.

Back: Spine is well-aligned.

Musculoskeletal: ROM-3/5 (bilateral knee joints). Reduced ROM of bilateral knee joints with crepitus. On palpation, the knee joints are tender.

Neurological:  Muscle strength 4/5; Stable body balance; CNs are intact.

Skin:  Brown skin with wrinkles on the hands and face.

Psychiatric (affect, mood): The self-reported is nervous, and affect is broad.

Diagnostic Results: Elevated erythrocyte sedimentation rate (ESR)- Normal

C-reactive protein (CRP)- Normal

WBC count- Normal

Rheumatoid factor-Negative

Assessment

Osteoarthritis (ICD 10- M19. 90): Osteoarthritis (OA) is a degenerative disease caused by the breakdown of articular cartilage in synovial joints. The typical symptom of OA is deep joint pain aggravated by extensive joint use (Yunus et al., 2020). It is also characterized by a reduced range of motion in affected joints and joint stiffness during rest. Morning joint stiffness also occurs lasting for not more than 30 minutes. In OA, inflammatory biomarkers such as ESR, CRP, and WBC are usually within the normal range (Yunus et al., 2020). OA is the presumptive diagnosis based on pertinent positive symptoms of joint pain, joint stiffness, morning stiffness, stiffness rest, and limitations in movement. In addition, findings of tenderness and a limited range of motion in the knee joint and negative Rheumatoid factor make OA the primary diagnosis.

Rheumatoid Arthritis (ICD 10- M06. 9): Rheumatoid arthritis (RA) presents with prominent and prolonged morning stiffness that persists for more than an hour. The affected joints are usually warm, swollen, tender, deformed, and have nodules with limited motion (Lin et al., 2020). In addition, WBC, ESR, and CRP levels are usually elevated, and rheumatoid factor is mostly positive in RA. Rheumatoid arthritis is a differential diagnosis based on the patient’s symptoms of morning joint stiffness, pain, and physical findings of tender knee joints (Lin et al., 2020). However, normal levels of WBC, ESR, CRP, and a negative rheumatoid factor makes RA an unlikely primary diagnosis.

Psoriatic arthritis (ICD 10- L40. 52): Psoriatic arthritis is a disorder frequently preceded by psoriasis. It is characterized by joint stiffness and pain. It also presents with heel pain, increased fatigue, and worsening symptoms with physical activity (Ocampo & Gladman, 2019). Physical examination findings include minimal joint tenderness, inflammation of digits, and sausage-like digits. Psoriatic arthritis is a differential diagnosis based on the patient’s symptoms of joint pain and stiffness and physical exam findings of joint tenderness (Ocampo & Gladman, 2019). However, the patient has no history of psoriasis, which rules out Psoriatic arthritis as a primary diagnosis.

Plan

Further Diagnostic Tests: Arthrocentesis of the knee joints within 12 hours. The test will exclude joint infection and inflammatory arthritis (Yunus et al., 2020).

Pharmacological Treatment:

Meloxicam- 7.5 mg PO OD for 2 weeks to relieve joint pain (Grässel & Muschter, 2020).

Non-pharmacological therapy: Occupational therapy for training on joint protection techniques and physical therapy techniques to enable the patient to perform her activities of daily living without limitations (Grässel & Muschter, 2020).

Heat and cold applications to alleviate joint stiffness and pain.

Patient Education:  Patient education will focus on measures to minimize stress on the knee joints. The patient will be recommended regular exercises to facilitate weight loss and reduce stress on the knee joints. Reducing stress on knee joints slows down the loss of cartilage in the joints (Grässel & Muschter, 2020). The patient will also be educated on healthy dietary measures to promote weight loss and thus reduce the load on the joints and increase joint mobilization.

Referrals/Consultations: Consultation with a Rheumatologist if symptoms do not improve for review of the treatment plan and specialized treatment (Grässel & Muschter, 2020).

Follow-Up: The patient will be scheduled for a follow-up appointment after four weeks to assess progress and monitor complications.

References

Grässel, S., & Muschter, D. (2020). Recent advances in the treatment of osteoarthritis. F1000Research, 9, F1000 Faculty Rev-325. https://doi.org/10.12688/f1000research.22115.1

Lin, Y. J., Anzaghe, M., & Schülke, S. (2020). Update on the Pathomechanism, Diagnosis, and Treatment Options for Rheumatoid Arthritis. Cells, 9(4), 880. https://doi.org/10.3390/cells9040880

Ocampo D, V., & Gladman, D. (2019). Psoriatic arthritis. F1000Research, 8, F1000 Faculty Rev-1665. https://doi.org/10.12688/f1000research.19144.1

Yunus, M., Nordin, A., & Kamal, H. (2020). Pathophysiological Perspective of Osteoarthritis. Medicine (Kaunas, Lithuania), 56(11), 614. https://doi.org/10.3390/medicina56110614

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please write a SOAP note for the condition osteoarthritis

Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up