Please see instructions attached along with assignment template and example. 

LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

TO PREPARE

· 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.

· 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 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.

Week 4 Lab Assignment:
Differential Diagnosis for Skin Conditions

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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): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.

Medications:

1.) Norvasc 10mg daily

2.) Combivent 2 puffs every 6 hours as needed

3.) Advair 500/50 daily

4.) Singulair 10mg daily

5.) Over the counter Tylenol 325mg as needed

6.) Over the counter Benefiber

7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs – rash

Cipro-headache

Past Medical History (PMH):

1.) Asthma

2.) Hypertension

3.) Osteopenia

4.) Allergic rhinitis

5.) Prostate Cancer

Past Surgical History (PSH):

1.) Cholecystectomy 1994

2.) Prostatectomy 1986

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

He has never smoked

Dipped tobacco for 25 years, no longer dipping

Denied ETOH or illicit drug use.

Immunization History:

Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna

Influenza Vaccination 10/3/2020

PNV 9/18/2018

Tdap 8/22/2017

Shingles 3/22/2016

Significant Family History:

One sister – with diabetes, dx at age 65

One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.

Lifestyle:

He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.

He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as need

Week 4

Skin Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

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