Walden – NURS 6512 Week 4 Soap Note – Lab Assignment: Differential Diagnosis for Skin Conditions

Module 3: Approach to System-Focused Advanced Health Assessments

What’s Happening in This Module?

Module 3: Approach to System-Focused Advanced Health Assessments is a 7-week module that spans Weeks 4–10. In this module, you explore advanced health assessments using a system-focused approach. Assessments such as skin, hair, and nails as well as head, neck eyes, ears, nose, and throat (HEENT) help you to begin considering abnormalities as you move forward in your assessments. You continue the module by assessing the abdomen and gastrointestinal system and move to other systems—such as heart, lungs, vascular, musculoskeletal, neurologic—before finishing with other special examinations.

What do I have to do?	When do I have to do it?
Review your Learning Resources.	Days 1–7, Weeks 4, 5, 6, 7, 8, 9, and 10
DCE: Health History Assessment	Complete and submit your DCE: Health History Assessment by Day 7 of Week 4.
Lab Assignment: Differential Diagnosis for Skin Conditions	Submit your Lab Assignment by Day 7 of Week 4.
Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat	Submit your Case Study Assignment by Day 6 of Week 5.
DCE: Focused Exam: Cough	Complete and submit your DCE: Focused Exam: Cough by Day 7 of Week 5.
Lab Assignment: Assessing the Abdomen	Submit your Lab Assignment by Day 7 of Week 6.
Midterm Exam	Complete by Day 7 of Week 6.
DCE: Focused Exam: Chest Pain	Complete and submit your DCE: Focused Exam: Chest Pain by Day 6 of Week 7.
Discussion: Assessing Musculoskeletal Pain	Post by Day 3 of Week 8 and respond to your colleagues by Day 6 of Week 8.
Case Study Assignment: Assessing Neurological Symptoms	Submit your Case Study Assignment by Day 6 of Week 9.
DCE: Comprehensive (Head-to-Toe) Physical Assessment	Complete and submit your DCE: Comprehensive Physical Assessment by Day 7 of Week 9.
Lab Assignment: Assessing the Genitalia and Rectum	Submit your Lab Assignment by Day 7 of Week 10.

Week 4: Assessment of the Skin, Hair, and Nails

Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.

This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.

Learning Objectives

Students will:

Apply assessment skills to diagnose skin conditions
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails

Learning Resources

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 9, “Skin, Hair, and Nails”

This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

This section explains the procedural knowledge needed prior to performing various dermatological procedures.

Chapter 1, “Punch Biopsy”

Chapter 2, “Skin Biopsy”

Chapter 10, “Nail Removal”

Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”

Chapter 16, “Skin Tag (Acrochordon) Removal”

Chapter 22, “Suture Insertion”

Chapter 24, “Suture Removal”

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.

Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

· Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)

VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals

This interactive website allows you to explore skin conditions according to age, gender, and area of the body.

Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282.

Document: Skin Conditions (Word document)

This document contains five images of different skin conditions. You will use this information in this week’s Discussion.

Document: Comprehensive SOAP Exemplar (Word document)

Document: Comprehensive SOAP Template (Word document)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Document: Shadow Health Support and Orientation Resources (PDF)

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Document: Student Acknowledgement Form (Word document)

Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.

Document: DCE (Shadow Health) Documentation Template for Health History (Word document)

Use this template to complete your Assignment 2 for this week.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 6, “The Skin and Nails”

In this chapter, the authors provide guidelines and procedures to aid in the diagnosis of skin and nail disorders. The chapter supplies descriptions and pictures of common skin and nail conditions.

Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from https://web.archive.org/web/20170215015223/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/absorbable_suture_chart.pdf

Ethicon, Inc. (2006). Dermabond topical skin adhesive application technique. Retrieved from https://web.archive.org/web/20150921174121/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_application_poster.pdf

Ethicon, Inc. (2001). Ethicon needle sales types. Retrieved from https://web.archive.org/web/20150921171922/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/needle_template.pdf

Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from https://web.archive.org/web/20150921202525/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/suture_chart_ethicon.pdf

Ethicon, Inc. (2002). How to care for your wound after it’s treated with Dermabond topical skin adhesive. Retrieved from https://web.archive.org/web/20150926002534/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_wound_care.pdf

Ethicon, Inc. (2005). Knot tying manual. Retrieved from https://web.archive.org/web/20160915214422/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/knot_tying_manual.pdf

Ethicon, Inc. (n.d.-c). Wound closure manual. Retrieved from http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure_Manual.pdf

Week 4 Soap Note Sample Paper

NURS 6512 Week 4 Soap Note – Lab Assignment: Differential Diagnosis for Skin Conditions

SOAP Note

Student’s Name:

Institutional Affiliation:

Comprehensive SOAP NOTE

Patient Initials: ___N/A____ Age: ___N/A____ Gender: ___N/A____

SUBJECTIVE DATA:

Chief Complaint (CC): #3

History of Present Illness (HPI): A Caucasian male whose age is unknown presents with non-scaly annual papules distributed along his nape. The papules have undiluted borders and appear reddish in color.

Medications: No medical history provided.

Allergies: No known allergies.

Past Medical History (PMH): Past medical history not provided.

Past Surgical History (PSH): No surgical history provided.

Sexual/Reproductive History: Not provided. Ask about his sexuality, the number of sexual partners, pregnancy, and whether the patient has a history of sexually transmitted infections.

Personal/Social History: Not provided. Enquire on his hobbies, place of work, traveling history, and whether he smokes or use any recreational drugs.

Immunization History: Not provided. Collect the patient immunization details.

Significant Family History: Not provided. Inquire if there are family members with any skin complications. Inquire about other family’s medical conditions that might contribute to skin infections.

Review of Systems:

General: Not reported. Inquire for symptoms of fatigue, fever, sweating, or any significant weight changes.

HEENT: Not reported. Inquire about any vision or hearing changes, any chewing or swallowing difficulty, and any nasal complications.

Neck: Red lesions distributed on the back of the neck.

Breasts: No reported complications. Ask if the patient has a history of lesions, masses, or rashes.

Respiratory: No reported complications.

CV: No reported complications.

GI: No reported complications.

GU: No reported complications. Ask if the patient has had any lesions or rashes on his genital areas.

MS: No reported complications.

Psych: No reported complications.

Neuro: No reported complications.

Integument/Heme/Lymph: Red lesions at the back of the neck. Ask if the lesions are present in other parts of the body.

Endocrine: No endocrine symptoms reported.

Allergic/Immunologic: No known allergies.

OBJECTIVE DATA

Physical Exam:

Check for the patient’s vital signs. Vital signs include blood pressure, temperature, heart rate, and body mass index.

General: Check for the patient’s appearance and signs of fatigue and discomfort.

HEENT: Investigate the eyes, ears, and nose for any abnormalities.

Neck: Non-scaly annual papules at the back of the neck. Palpate the lesions to determine the texture and warmness.

Chest/Lungs: Check the chest for the presence or rashes or lesions.

Heart/Peripheral Vascular: N/A

ABD: Check the abdomen for the presence of rashes or lesions

Genital/Rectal: Investigate the genitalia for the presence of rashes.

Musculoskeletal: N/A

Neuro: N/A

Skin/Lymph Nodes: Non-scaly annual lesions at the back of the neck. Check whether there are further lesions on other skin regions.

ASSESSMENT:

Diagnostics:

Lab:

Various laboratory procedures can be used to guide the diagnosis. The following are some of the recommended procedures.

Dermoscopy. The procedure uses a skin surface microscope known as a dermatoscope to magnify the lesion (Colyar, 2015). The process aims at providing a more detailed investigation of the lesion to make a diagnosis and determine the skin lesions that require a biopsy (Colyar, 2015).

Diascopy. The process involves pressing a glass or plastic slide on the lesion and noting any color changes (Colyar, 2015). The procedure determines whether determining the type of lesions. For example, whether it is hemorrhagic or not (Colyar, 2015).

Punch Biopsy. This involves collecting a cylindrically shaped tissue sample (Colyar, 2015). The medical practitioner first cleans the skin and administers local anesthesia. The practitioner then stretches the skin and rotates a biopsy instrument while exerting downward pressure (Colyar, 2015). The procedure obtains a specimen that is then sent for culture to identify the bacteria or virus, causing the condition (Colyar, 2015).

Differential Diagnosis (DDx):

Tinea corporis. This is a skin condition that causes red, itchy, and circular rashes on the skin (Halder & Nootheti, 2014). Symptoms include itchy ring-shaped lesions that appear commonly on the arms and legs (Halder & Nootheti, 2014). However, the rashes may also appear on any part of the body. The rings may also overlap and appear red in color (Halder & Nootheti, 2014). Common causes of tinea corporis are skin to skin contact with an infected person or an animal (Halder & Nootheti, 2014).

Pityriasis rosea. This is a form of skin rash that starts as an oval spot on the back or the chest that then spreads to the other body parts (Halder & Nootheti, 2014). It commonly affects individuals between ages 10-35 and may clear on its own after around ten weeks (Halder & Nootheti, 2014). Symptoms of the condition are large and slightly raised red patches, fatigue, fever, and itching (Halder & Nootheti, 2014). The causes of pityriasis rosea are not clearly known, but some viruses are suspected of causing the infection (Halder & Nootheti, 2014).

Lupus. This is an autoimmune infection that occurs when the immune system attacks the body’s tissues and organs (Halder & Nootheti, 2014). Lupus causes an inflammation that may affect the skin, lungs, brain, kidneys, or joints (Halder & Nootheti, 2014). Lupus can be difficult to diagnose since it affects various body parts, and the symptoms vary from the type of lupus (Halder & Nootheti, 2014). Some symptoms of Lupus include red skin lesions that appear in areas exposed to the Sun., butterfly-shaped rashes in various body parts, fever, fatigue, chest pain, dry eyes, and headaches (Halder & Nootheti, 2014).

Guttate psoriasis. This is a form of a skin condition that appears as a red small itchy lesion (Dains, Baumann, & Scheibel, 2015). It is a form of an autoimmune disease that might occur more than once in a lifetime (Dains et al., 2015). Gutate psoriasis usually occurs on the face, ears, scalp, neck, legs, and arms (Dains et al., 2015). Guttate psoriasis is usually caused by bacterial infections, especially streptococcus (Dains et al., 2015). In some cases, genetic factors can play a role if there are several family members with the condition (Dains et al., 2015).

Patient’ problem/diagnosis:

Granuloma annulare. This a skin condition that causes circular reddish lesions. It is usually triggered by skin injuries or particular drugs (Halder & Nootheti, 2014). The condition may disappear on its own after approximately two years without treatment (Halder & Nootheti, 2014). However, treatment can help speed up healing. The symptoms of granuloma annulare depend on the type of infection (Halder & Nootheti, 2014). For example, localized granuloma annulare causes skin-colored lesions that occur on the feet, wrists, and hands (Halder & Nootheti, 2014). Generalized granuloma annulare causes red lesions on areas such as the neck, legs, and arms (Halder & Nootheti, 2014). The lesions in granuloma annulare are usually annular bumps that might spread to various parts of the body (Halder & Nootheti, 2014).

Discussion:

Making a diagnosis for skin conditions can be difficult since the symptoms are often similar to those of other conditions. In the case of this discussion, it is particularly difficult because the patient was not physically present, and the diagnosis depended on an image interpretation. The selected primary diagnosis for this discussion was granuloma annulare because the patient had symptoms of non-scaly annual papules distributed along his nape. The symptoms are similar to what shows in cases of granuloma annulare. However, it is also possible for the patient to have conditions such as tinea corporis, pityriasis rosea, and lupus because the conditions also manifest red circular lesions in some cases. Therefore, further lab assessment and physical exams may be needed for an accurate diagnosis.

References