26 Sep Review the Skin Conditions document provided in this weeks Learning Resources, and select one condition to closely examine for this Lab Assignment. Consider the abnormal physical
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.
Running header: Lab Assignment: Differential Diagnosis for Skin Conditions 1
Lab Assignment: Differential Diagnosis for Skin Conditions:
Skin Condition Graphic # 4
Master of Science in Nursing, Walden University
NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
March 26, 2022
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Lab Assignment: Differential Diagnosis for Skin Conditions 2
Week 4
Skin Comprehensive SOAP Note Template
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Lab Assignment: Differential Diagnosis for Skin Conditions 3
Patient Initials: JC Age: 65 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): JC is a 65-year-old African American female who presents to
the clinic with complaint of skin condition graphic No. 4.
History of Present Illness (HPI): The patient states that she observed some redness and
swelling in the left lower extremity about two weeks ago. Stated that the affected area
felt hot and tender to touch. The skin of the affected area is red in color and it is noted
with inflammation and swelling. JC stated that she thought it would go away, and that
she had a similar experience last year on the same leg which was treated with antibiotics,
but she was unable to recall the name of the antibiotics. JC stated that the affected area is
developing a sore that appears to be spreading. JC added that she felt pain and the red
area of skin that tends to expand, with swelling, warm and painful, pain rating was 7/10.
JC also endorsed fever, and that she shakes often, that she has chills and was not feeling
well.
Medications:
1. Metformin 1000 mg once daily (with dinner) for Diabetes II.
2. Advil 400 mg every 6 hours as needed for pain.
Allergies: No known allergies
Past Medical History (PMH):
1. Diabetes II,
2. Obesity
Past Surgical History (PSH): None
Sexual/Reproductive History: Heterosexual
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Lab Assignment: Differential Diagnosis for Skin Conditions 4
Personal/Social History:
Use alcohol occasionally,
Never smoked
Denied use of illicit drugs
Health Maintenance:
JC has health insurance from her job, undergoes annual health and physical with
primary care doctor, is compliant with medications. JC states that she was most
recently hospitalized in January 2022 for diabetic crisis, with blood sugar 538.
Stated that she had stopped taking her metformin due to temporary loss of
employment. JC is registered at a gym and tries to limit her intake of
carbohydrates in her diet.
Immunization History:
Influenza Vaccination in September 2021
Covid Vaccine declined
Up to date with all other immunizations
Significant Family History:
Mother has a history of diabetes type II
Father has a history of Hypertension,
Brother has no health problems.
Review of Systems:
General: Pt complains of pain to lower extremity, denies chills, and no decrease in
appetite.
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Lab Assignment: Differential Diagnosis for Skin Conditions 5
HEENT: Denies headache, dizziness, no problems with vision or hearing, no nasal
problems, no difficulty chewing or swallowing.
Respiratory: No respiratory distress, normal effort. Bilateral air entry equally. There is
good respiratory effort with symmetrical thoracic expansion. Lungs are clear to
auscultation.
Cardiovascular/Peripheral Vascular: No issues, denies chest pain or dizziness
Gastrointestinal no change in bowel habits, No nausea, no vomiting, no diarrhea, no
constipation, no melena, no anorexia. Bowel sounds are normoactive. There is no
tenderness. There is no guarding, rebound tenderness, hepatosplenomegaly, or palpable
mass.
Genitourinary: Denies hematuria, nocturia, discharge, dysuria, incontinence, change in
urinary frequency, urinary retention.
Musculoskeletal: Denies muscle pain or weakness.
Neurological: There are no tremors.
Psychiatric: Cooperative, calm. No anxiety, no depression, no suicidal ideation
Skin/hair/nails: There is 2+ left lower extremity and ankle edema with redness,
swelling and pain.
OBJECTIVE DATA:
Physical Exam:
Vital signs: HR 69 BPM RR 22 BP 157/59 BP SpO2 99% HT:170 cm WT:95 kg,
BMI:32. Pain Assessment Primary: Numeric Pain Score: 7/10
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Lab Assignment: Differential Diagnosis for Skin Conditions 6
General: The patient is well groomed, well-developed, well-nourished. In no acute
distress, alert and oriented ×3. Left lower extremity skin appears swollen and red and
painful and warm to the touch.
HEENT: Normocephalic, atraumatic, Normal lids and conjunctiva, anicteric, PERRLA.
Nasal mucosa is without epistaxis or rhinorrhea. Oral mucosa is dry. Neck is supple, no
thyromegaly or thyroid mass.
Chest/Lungs: Normal respiratory effort with symmetrical thoracic expansion. Bilateral
air entry equally. Lungs are clear to auscultation.
Heart/Peripheral Vascular: regular rhythm rate, S1-S2 normal. No gallops or murmurs.
Palpable pulses bilaterally,
Abdomen: Soft and non-tender to palpate, positive bowel sounds in all quadrants.
Genital/Rectal: Declined exam
Musculoskeletal: Strength is 5/5 of the upper and lower extremities bilaterally without
focal deficit.
Neurological: No facial asymmetry, Cranial nerves II through XII grossly intact. There
are no tremors.
Skin: Warm and dry, there is 2+ left lower leg and ankle edema with erythema.
Diagnostic results:
1. Covid PCR: negative
2. EKG: Normal sinus rhythm
3. LLE X-Ray: negative for fractures
4. CBC: WBC 14.6
5. Random Blood Glucose: 285
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Lab Assignment: Differential Diagnosis for Skin Conditions 7
ASSESSMENT:
Differential Diagnosis (DDx):
1. Statis Dermatitis: Stasis dermatitis is a frequent cause of bilateral leg redness, usually
presents with no systemic signs or leukocytosis; commonly occurs bilaterally with
pruritus and red-brown dyspigmentation (VisualDX, 2021). Stasis is a term used to
describe leg swelling seen in conditions of poor circulation and fluid buildup (VisualDX,
2021).
2. Necrotizing fasciitis: Necrotizing fasciitis is a deep and often devastating bacterial
infection that tracks along fascial planes and expands well beyond any outward cutaneous
signs of infection such as erythema (VisualDX, 2021). Necrotizing fasciitis are often
mistaken for cellulitis that is not responding to standard antibiotic therapy (VisualDX,
2021). Necrotizing fasciitis most commonly involves the lower extremities, with the
presence of signs of systemic illness such as fever, lethargy, hypotension, and tachycardia
(VisualDX, 2021).
3. Erysipelas: Erysipelas is a superficial bacterial infection of the skin most often caused
by beta-hemolytic group A streptococci (Streptococcus pyogenes), which involves the
lymphatics of the superficial dermis (VisualDX, 2021). Erysipelas is more commonly
seen on the lower extremities in patients with venous insufficiency and stasis dermatitis
(VisualDX, 2021).
4. Statis Ulcer: A stasis ulcer is a breakdown of the skin (ulcer) caused by fluid build-up in
the skin from poor vein function (venous insufficiency) (VisualDX, 2021). Women are
more often affected by stasis ulcers than men and the risk for acquiring a stasis ulcer
includes overweight (VisualDX, 2021).
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Lab Assignment: Differential Diagnosis for Skin Conditions 8
Primary Diagnoses:
Cellulitis: Cellulitis is a common bacterial infection of the deep dermis and subcutaneous
tissue characterized by erythema, pain, warmth, and swelling; most often caused by the
bacteria Streptococcus or Staphylococcus (VisualDX, 2021). There are no conclusive
tests to determine whether or not you have cellulitis (O’Brien & White, 2021). The Red
Leg RATED tool featured descriptive criteria and photos for identifying cellulitis, as well
as management and follow-up suggestions (O’Brien & White, 2021). Neill et al. (2019)
also suggest a mnemonic for diagnosing Cellulitis which is CELLULITIS: Cellulitis
history, Edema, Local warmth, Lymphangitis, Unilateral, Leukocytosis, Injury, Tender,
Instant onset, and Systemic signs. The first trait has the highest OR and is possibly the
easiest to remember, which is past history of cellulitis (Neill et al., 2019). Cellulitis can
affect any part of the body, but the most common locations are lower legs, arms or hands,
and face (VisualDX, 2021). So based on the referenced researches, given the fact that
there are no conclusive tests to pin point cellulitis, and JC has a past medical history of
the same characteristics, the most likely diagnosis for JC is Cellulitis. Cellulitis involves
a variety of differential diagnoses that result in red, heated, painful swollen limbs
(O’Brien & White, 2021).
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be
required for future courses.
References
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Lab Assignment: Differential Diagnosis for Skin Conditions 9
Neill, B. C., Stoecker, W. V., Hassouneh, R., Rajpara, A., & Aires, D. J. (2019).
CELLULITIS: A mnemonic to increase accuracy of cellulitis diagnosis.
Dermatology Online Journal, 25(1).
O’Brien, G., & White, P. (2021). The Red Legs RATED tool to improve diagnosis of
lower limb cellulitis in the emergency department. British Journal of Nursing (Mark
Allen Publishing), 30(12), S22–S29. https://doi.org/10.12968/bjon.2021.30.12.S22
VisualDx. (2021). Clinical decision support: For professionals. Retrieved March 22, 2022, from
http://www.skinsight.com/professionals
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,
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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