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Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions

  

Properly 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 Lab 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 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 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.

Submit your Lab Assignment. 

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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Week

4

S

kin

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:

Genitou

rinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin

/hair/nails

:

OBJECTIVE DATA:

© 2021 Walden University Page 1 of 2

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:

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 needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.

Review 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; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.

Neck: Denies pain, injury, or history of disc disease or compression..

Breasts:. Denies history of lesions, masses or rashes.

Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.

CV: denies 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: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.

GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.

MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.

Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.

Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.

Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.

Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyromegally

Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD: nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: pt declined for this exam

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

Diagnostics/Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Covid PCR-neg

Influenza- neg

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Spirometry- FEV1 65%

Assessment:

Differential Diagnosis (DDx):

1.) Asthmatic exacerbation, moderate

2.) Pulmonary Embolism

3.) Lung Cancer

Primary Diagnoses:

1.) Asthmatic Exacerbation, moderate

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

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Walden University

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2

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 C

omplaint

(

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

day

s

, fever, muscle aches,

loss of taste and smell for t

he last three days.

H

e reported that the “cold feels like it

is descending into h

is

chest

and he can’t eat much

”. The cough is nagging and

productive.

H

e brought in a few paper towels with expectorated phlegm

–

yellow/

green

in color.

H

e has

associated symp

toms

of dyspnea of exertion and

f

atigue

. H

is

Tmax was reported to be 10

0

.

3

, last night.

H

e has been taking

Tylenol

325

mg about every 6 hours and the fever breaks, but returns after the medication

wears off.

He

rated the severity of her symptom discomfort a

t

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 rhin

itis

5.) Prostate Cancer

Past Surgical History (PSH):

1.)

Cholecystectomy

1994

2.)

Prostatectomy 1986

© 2021 Walden University Page 1 of 2

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

Week 4 Lab Assignment:
Differential Diagnosis for Skin Conditions

1:

2:

3.

4.

5.

© 2021 Walden University

       

                       

                             

                               

                                   

                             

                                   

                                 

                         

                               

                             

                               

                             

                                   

                     

                                   

                           

                                 

 

                               

                                   

             

         

                   

                             

 

                         

     

       

         

                               

C H A P T E R 2 8

Rashes and skin lesions

Dermatologic problems result from a number of mechanisms, including inflammatory, infectious, immunologic,
and environmental (traumatic and exposure induced). At times, the mechanism may be readily identified, such
as the infectious bacterial etiology in impetigo. However, some dermatologic lesions may be classified in more
than one way. Most insect bites, for example, involve both environmental (the bite) and inflammatory (the
response) mechanisms. Awareness of the potential mechanism of any skin disorder is most helpful in
identifying the risk a person may have for other illnesses. For example, people with eczema are also frequently
at risk for other atopic conditions, notably asthma and allergic rhinitis. Thousands of skin disorders have been
described, but only a small number account for the majority of patient visits.
Evaluation of rashes and skin lesions depends on a carefully focused history and physical examination. The

provider needs to be familiar with the characteristics of various skin lesions; anatomy, physiology, and
pathophysiology of the skin; clinical appearance of the basic lesion; arrangement and distribution of the lesion;
and associated pathological conditions. It is also important to know common symptoms associated with specific
lesions such as itching or fever. It is necessary to quickly identify life-threatening diseases and those that are
highly contagious. Ultimately, competence in dermatologic assessment involves recognition through repetition.

Diagnostic reasoning: Initial focused physical examination

Initial inspection
Dermatologic assessment is similar to the assessment of most other body systems in that it depends on patient
history and physical assessment. However, sometimes a brief physical assessment preceding the history can
assist in the development of the initial differential diagnoses followed by a focused history and further physical
examination.

Morphologic criteria
Examination involves the classification of the lesion based on a number of morphologic features (examples are
listed in Tables 28.1 and 28.2 and illustrated in Figs. 28.1 and 28.2). Evaluation should be systematic. Generally,
morphologic features should be analyzed as follows:

• Identify the location of the lesion(s).
• Identify the distribution of the lesions as localized, regional, or generalized.
• Identify whether the lesion is primary (appearing initially) or secondary (resulting from a change in a
primary lesion).

• Identify the shape of the lesion and any arrangement if numerous lesions are present.
• Assess the margins (borders).
• Assess the pigmentation, including variations.
• Palpate to assess texture and consistency.
• Measure the size of an individual lesion or estimate the size if lesions are numerous or widespread.

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FIGURE 28.1 Types of skin lesions. Source: (From, Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to
physical examination, ed. 8, St. Louis, 2015, Elsevier.)

FIGURE 28.2 Typical distribution of papulosquamous eruptions in children. A, Atopic dermatitis:
usually located on the cheeks, creases of elbows, and knees. B, Seborrheic dermatitis: usually
located on the scalp, behind the ears, in thigh creases, and in eyebrows. C, Scabies: usually
located on the axillae, webs of fingers and toes, and intragluteal area. Source: (From Berkowitz C:
Pediatrics: A primary care approach, ed. 2, Philadelphia, 2000, Saunders.)

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Table 28.1

Morphologic Criteria of Rashes and Skin Lesions

PRIMARY LESIONS (DEVELOP INITIALLY IN RESPONSE TO CHANGE IN INTERNAL OR
EXTERNAL ENVIRONMENT OF SKIN)

Macule Discrete flat change in color of skin; usually
<1.5-cm diameter

Freckle, lentigo, purpura

Patch Discrete flat lesion (large macule); usually
>1.5-cm diameter

Pityriasis rosea, melasma, lentigo

Papule Discrete palpable elevation of skin; <1-cm
diameter; origin may be epidermal, dermal,
or both

Nevi, seborrheic keratosis,
dermatofibroma

Nodule Discrete palpable elevation of skin; may evolve
from papule; may involve any level of skin
from epidermis to subcutis

Nevi, basal cell carcinoma,
keratoacanthoma

Plaque Slightly raised lesion, typically with flat
surface; >1-cm diameter; scaling frequently
present

Psoriasis, mycosis fungoides

Urticaria

NATURE OF
DESCRIPTION EXAMPLES

LESION

Wheal Transient pink/red swelling of skin; often
displaying central clearing; various shapes
and sizes; usually pruritic and lasts <24 hr

Tumor Large papule or nodule; usually >1-cm
diameter

Pustule Raised lesion <0.5-cm diameter containing
yellow cloudy fluid (usually infected)

Vesicle Raised lesion <0.5-cm diameter containing
clear fluid

Bulla Vesicle >0.5-cm diameter

Cyst Semisolid lesion; varies in size from several
mm to several cm; may become infected

Basal cell carcinoma, squamous cell
carcinoma, malignant melanoma

Folliculitis, acne (closed comedones)

Herpes simplex, herpes zoster, contact
(irritant) dermatitis

Bullous pemphigoid, contact (irritant)
dermatitis, blisters of second-
degree sunburn

Sebaceous cyst

SECONDARY LESIONS (APPEAR AS RESULT OF CHANGES IN PRIMARY LESIONS)

Crust

Scale

Excoriation

Dried exudate that may have been serous,
purulent, or hemorrhagic

Thin plates of desquamated stratum corneum
that flake off rather easily

Shallow hemorrhagic excavation; linear or
punctate; results from scratching

Lichenification Thickening of skin with exaggeration of skin
creases; hallmark of chronic eczematous
dermatitis

Erosion Partial break in epidermis

Impetigo, herpes zoster (late phase)

Xerosis, ichthyosis, psoriasis

Contact (irritant) dermatitis

Chronic eczema

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NATURE OF
DESCRIPTION EXAMPLES

LESION

Herpes simplex or zoster, pemphigus
vulgaris

Fissure Linear crack in epidermis Xerosis, angular cheilitis, severe
eczema

DISTRIBUTION OF LESIONS

Localized Lesion appears in one small area Impetigo, herpes simplex (e.g.,
labialis), tinea corporis
(“ringworm”)

Regional Lesions involve specific region of body Acne vulgaris (pilosebaceous gland
distribution), psoriasis (extensor
surfaces and skinfolds)

Generalized Lesions appear widely distributed or in
numerous areas simultaneously

Urticaria, disseminated drug eruptions

SHAPE AND ARRANGEMENT

Round or discoid Coin or ring shaped (no central clearing) Nummular eczema

Oval Ovoid shape Pityriasis rosea

Annular Round, active margins with central clearing Tinea corporis, sarcoidosis

Zosteriform
(dermatomal)

Following nerve or segment of body Herpes zoster

Polycyclic Interlocking or coalesced circles (formed by
enlargement of annular lesions)

Psoriasis, urticaria

Linear In a line Contact dermatitis

Iris/target lesion Pink macules with purple central papules Erythema multiforme

Stellate Star shaped Meningococcal septicemia

Serpiginous Snakelike or wavy line track Cutanea larva migrans

Reticulate Netlike or lacy Polyarteritis nodosa, lichen planus
lesions of erythema infectiosum

Morbilliform Confluent and salmon colored Rubeola

BORDER OR MARGIN

Discrete Well demarcated or defined; able to draw a
line around it with confidence

Psoriasis

Indistinct Poorly defined; having borders that merge into
normal skin or outlying ill-defined papules

Nummular eczema

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Active Margin of lesion shows greater activity than
center

Tinea species eruptions

Irregular Nonsmooth or notched margin Malignant melanoma

Bo