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Assignment 1: Differential Diagnosis for Skin Conditions

Assignment 1: Differential Diagnosis for Skin ConditionsAssignment 1: Differential Diagnosis for Skin ConditionsProperly 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 Assignment, 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.To prepare:Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this 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.Download the SOAP Template found in this week’s Learning Resources.Assignment 1: Differential Diagnosis for Skin ConditionsORDER A PLAGIARISM-FREE PAPER HERETo complete: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.Assignment 1: Differential Diagnosis for Skin ConditionsReminder: Please make sure the paper includes introduction (including a purpose statement) and peer reviewed references. Lastly please follow uploaded rubric. ThanksComprehensive SOAP Template  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= locationD= duration (recent/chronic)C= characterA= associated symptoms/aggravating factorsR= relieving factorsT= treatments previously tried – response? Why discontinued?S= severityAssignment 1: Differential Diagnosis for Skin ConditionsSUBJECTIVE 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:LocationQualityQuantity or severityTiming, including onset, duration, and frequencySetting in which it occursFactors that have aggravated or relieved the symptomAssociated 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. Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations., and 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.Assignment 1: Differential Diagnosis for Skin ConditionsImmunization 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. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan textGeneral: 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:Assignment 1: Differential Diagnosis for Skin ConditionsOBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam.. Do not use “WNL” or “normal.” You must describe what you see. Physical Exam:Vital signs: Include vital signs, ht, wt, and BMI. Pulse Ox, Pain level.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:ChestLungs:HeartPeripheral Vascular: Abdomen:Genital/Rectal:Musculoskeletal:Neurological:Skin:Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses IF YOU ALREADY HAVE RESULTS.Assignment 1: Differential Diagnosis for Skin ConditionsASSESSMENT: 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 non-pharmacological 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: Reflect on your clinical experience, and 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? This is worth 25 points! References: Should use two peer-reviewed journal articles or references to support your reflection and differentials as well as any textbooks used.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.Assignment 1: Differential Diagnosis for Skin ConditionsPatient 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. 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:Lisinopril 10mg dailyCombivent 2 puffs every 6 hours as neededSerovent dailySalmeterol dailyOver-the-counter Ibuprofen 200mg -2 PO as neededOver-the-counter BenefiberFlonase 1 spray each night as needed for allergic rhinitis symptomsAssignment 1: Differential Diagnosis for Skin ConditionsAllergies: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 controlled3.) Gastroesophageal reflux (GERD) – quiet, on no medication4.) Osteopenia5.) Allergic rhinitis Past Surgical History (PSH):Cholecystectomy 1994Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History:HeterosexualG1P1A0Non-menstruating – TAH 1998Assignment 1: Differential Diagnosis for Skin ConditionsPersonal/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.Assignment 1: Differential Diagnosis for Skin ConditionsReview 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. Breasts: No reports of breast changes. 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.Assignment 1: Differential Diagnosis for Skin ConditionsGU: 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 21Assignment 1: Differential Diagnosis for Skin ConditionsGeneral: A&O x3, NAD, appears mildly uncomfortableHEENT: PERRLA, EOMI, oronasopharynx is clearNeck: Carotids no bruit, jvd or tmegallyChest/Lungs: CTA AP&LHeart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radialABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no reboundGenital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.Musculoskeletal: symmetric muscle development – some age-related atrophy; muscle strengths 5/5 all groupsNeuro: CN II – XII grossly intact, DTR’s intactSkin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes ASSESSMENT: Lab Tests and Results:CBC – WBC 15,000 with + left shiftSAO2 – 98% Diagnostics:Lab:Radiology:CXR – cardiomegaly with air trapping and increased AP diameterECGNormal sinus rhythm Differential Diagnosis (DDx):Acute BronchitisPulmonary EmbolisLung CancerAssignment 1: Differential Diagnosis for Skin ConditionsDiagnoses/Client Problems: 1.) COPD2.) HTN, controlled3.) Tobacco abuse – 40-pack-a-year history4.) Allergy to sulfa drugs – rash5.) 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.]Rubric Detail Excellent             Good     Fair         Poor Quality of Work Submitted: The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.   27 (27%) – 30 (30%)Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.24 (24%) – 26 (26%)Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.Assignment 1: Differential Diagnosis for Skin Conditions21 (21%) – 23 (23%)Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed.0 (0%) – 20 (20%)Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.  Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to: Understand and interpret the assignment’s key concepts.           27 (27%) – 30 (30%)Demonstrates the ability to critically appraise and intellectually explore key concepts.24 (24%) – 26 (26%)Demonstrates a clear understanding of key concepts.21 (21%) – 23 (23%)Shows some degree of understanding of key concepts.0 (0%) – 20 (20%)Shows a lack of understanding of key concepts, deviates from topics.  Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to: Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.       18 (18%) – 20 (20%)Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to support point of view.16 (16%) – 17 (17%)Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view.Assignment 1: Differential Diagnosis for Skin Conditions14 (14%) – 15 (15%)Minimally includes and integrates specific information from 2-3 resources to support major points and point of view.0 (0%) – 13 (13%)Includes and integrates specific information from 0 to 1 resource to support major points and point of view.  Written Expression and Formatting Paragraph/Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.   9 (9%) – 10 (10%)Paragraphs/Sentences follow writing standards for structure, flow, continuity and clarity8 (8%) – 8 (8%)Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 80% of the time.7 (7%) – 7 (7%)Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 60%- 79% of the time.0 (0%) – 6 (6%)Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time. Assignment 1: Differential Diagnosis for Skin ConditionsWritten Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation.  5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.3 (3%) – 4 (4%)Contains a few (1-2) grammar, spelling, and punctuation errors.2 (2%) – 2 (2%)Contains several (3-4) grammar, spelling, and punctuation errors.0 (0%) – 1 (1%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.  Written Expression and Formatting The assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.      5 (5%) – 5 (5%)Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.3 (3%) – 4 (4%)Contains parenthetical/in-text citations and at least 2 evidenced based references are listed2 (2%) – 2 (2%)Assignment 1: Differential Diagnosis for Skin ConditionsContains parenthetical/in-text citations and at least 1 evidenced based reference is listed0 (0%) – 1 (1%)Contains no parenthetical/in-text citations and 0 evidenced based references listed.Differential Diagnosis for Skin ConditionsStudent’s NameInstitutional Affiliation  Differential Diagnosis for Skin ConditionsThe skin is a membranous barrier between the body’s outer and inner environment, thus responds to external and internal alterations. Skin conditionis a common presentation among patients. Most skin diseases have similar symptoms hence the high potential for misdiagnosis. Propertaking of patient’s problem-focused history, physical assessment and investigations are important in the identification of the cause, correct diagnosis and other differential diagnosis ofother skin conditions. This enables the patient to receive the correct and prompt treatment.One of the common skins is psoriasis,a chronic immune-mediated inflammatory skin condition manifested by thickened erythematous scaly plaques.It affects the skin and joint. The commonest type is psoriasisvulgaris. Psoriasis is caused d by genetic, epigenetic and environmental factors (Kim, W. B., Jerome, D., &Yeung, J., 2017).Assignment 1: Differential Diagnosis for Skin Conditions                                                  Subjective DataChief complain (skin condition graphic number 5): Patients presents with erythematous and whitish scaly plaques on the chest.History of presenting illness: Patient was well until a few weeks ago when had had the erythematous and whitish scaly plaques that are itchy on the chest.He has never had similar symptoms.Past Medical History (PMH): She has had varicella, recurring tonsillitis,and appendicitis.Past Surgical History (PSH): She underwent tonsillectomy in 2012 and appendectomy in 2004.Sexual/Reproductive History: She is heterosexual, G0P0A0, menarche at ageof eleven years with regularmenstruation. Currently, she is sexually active, has been on oral contraceptionfor seven years and denies any risky sexual behaviors.She did her last Pap smear in 2014 with normal resultsSocial History: She denies the use of tobacco, ETOH, and illicit drugs.  She reports regular exercisingand takinga healthy diet.Immunization History: Her immunizations are up to date, lastTdap was in 2010 and she has received her flu vaccine for the year.  She does not meet criteria for receiving the pneumococcal vaccinationcurrently.Family History:Her mother aged 45 years hasa history of breast cancer in 2007 but currently in remission. Her father aged 50 years hasa history of eczema and multiple allergies.Maternal grandfather aged 71 years has a history of psoriasis and psoriatic arthritis.Paternal grandmother aged 73 years hasa history of eczema and psoriasis.Her two brothers aged 16 and 20 have a recent history of fungal infections.Assignment 1: Differential Diagnosis for Skin ConditionsObjective dataHer vital signs were normal. No investigations were done.AssessmentGeneral: patient appears anxious and distressedSkin: Patient has erythematous and whitish scaly plaques on the chest. They are sharply demarcated and indurated. She had painful and itchy lesions. Nothing abnormal on the nails.Assignment 1: Differential Diagnosis for Skin ConditionsHEENT: Nothing abnormal noted on the scalp, eyes, and ears.Neck: Swollen cervical lymph nodesLungs: Normal breath sounds notedAbdomen: No abdominal distension and tenderness noted   DiagnosisPsoriasis is a chronic recurrent inflammatory disease affecting mostly the skin and is caused by a  combination of genetic, epigenetic and environmental factors.  Its genetic and epigenetic aspects can be influenced by environmental factors such as; infections, cigarette smoking, alcohol abuse andstress leadingto psoriasis (Jinrong Z, Shuaihantian L, Yumeng H,  &Qianjin L.,2017).Ann’s has a positive history of psoriasis form her maternal grandfather. Her mother had a child a month ago;she lived in a cramped house, sleeps on the couch and often stays up late. She currently under her parent’s health insurance plan and has a strained supportsystem. Also, she has not made friends at her new jobyet. She also had siblings who had been treated for fungal infections. A combination of these genetic and environmental factors predisposes her to psoriasis(BoehnckeW.H&Schon M.P., 2015). Other than the physical effects of the disease; it is associated  with emotional and psychological problems like stigmatization, stress and low self-esteem that affect an individual’s social life and interpersonal relationships (Stawczyk-Macieja M, Rębała K, Szczerkowska-Dobosz A, Wysocka J,Cybulska L, Kapińska E, et al.,2016).Assignment 1: Differential Diagnosis for Skin ConditionsDifferential diagnosis for psoriasisAtopic Dermatitis is a skin condition characterized by pruritusand flexurallichenification.Contact dermatitis is described as patches or plaques with sharp margins caused by exposure to the environmental irritant or allergic materials.Pityriasisrosea is pinkish oval papules and patches on trunk but rarely on the face and lower extremities.Secondary syphilis characterized by red colored lesions often involving the palms and solesFungal Mycosis presents with asymmetric lesions irregular in shape and wrinkling in appearance (Kim, W. B., Jerome, D., &Yeung, J., 2017).Assignment 1: Differential Diagnosis for Skin ConditionsPlanPerform skin scraping or biopsy to confirm the diagnosis of psoriasis.Topical treatment through the use of Corticosteroidsfor mildpsoriasis.Also, Vitamin D3 analogues such as Calcipotriolis used for plaque and severe scalp psoriasis (National Psoriasis Foundation. (2016).Systemic therapy such as phototherapy is used formoderateand severe psoriasis and in patients who are unresponsive to topical treatment. Methotrexatehascytostatic and anti-inflammatory properties for treatment of severe psoriasis.Cyclosporine is effectiveinthe treatment of severe psoriasis and psoriatic arthritis (Kim, W. B., Jerome, D., &Yeung, J., 2017).ConclusionSkin conditions are very common. There are numerous skin conditions that can be managed effectively if properly and promptly diagnosed. Such skin condition is psoriasis, a disfiguring and psychologically disturbing condition. Proper diagnosis and treatment by use of topicaland systemic therapy is vital in the management of these patients.Assignment 1: Differential Diagnosis for Skin Conditions  ReferencesBoehncke W.-H., Schon M.P. (2015).Psoriasis.The Lancet, 386  (9997) , pp. 983-994.Jinrong ZENG, Shuaihantian LUO, Yumeng HUANG,  &Qianjin LU.(2017).Critical role of environmental factors in the pathogenesis of psoriasis .Journal of Dermatology 2017; 44: 863–872. doi: 10.1111/1346-8138.13806Kim, W. B., Jerome, D., &Yeung, J. (2017).Diagnosis and management of psoriasis. Canadian Family Physician, 63(4), 278–285.National Psoriasis Foundation.(2016).About psoriasis. National Psoriasis Foundation (accessed 11 Oct 2016).Stawczyk-Macieja M, Rębała K, Szczerkowska-Dobosz A, Wysocka J, Cybulska L, Kapińska E, et al. (2016). Evaluation of Psoriasis Genetic Risk Based on Five Susceptibility Markers in a Population from Northern Poland. PLoS ONE 11(9): e0163185. 1: Differential Diagnosis for Skin Conditions

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