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Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions Photo Credit: Getty Images/iStockphoto 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 weeks 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. Learning Resources Required Readings (click to expand/reduce) Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidels 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 Seidels guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidels 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 Seidels guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidels 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. 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 its 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   Required Media (click to expand/reduce) Module 3 Introduction Dr. Tara Harris reviews the overall expectations for Module 3. Consider how you will manage your time as you review your media and Learning Resources for your Discussions, Case Study Lab Assignments, DCE Assignments, and your Midterm exam (12m). Accessible player --Downloads--Download Video w/CCDownload AudioDownload Transcript Skin, Hair, and Nails - Week 4 (19m) Accessible player --Downloads--Download Video w/CCDownload AudioDownload Transcript Online media for Seidels Guide to Physical Examination In addition to this weeks media, it is highly recommended that you access and view the online resources included with the text, Seidels Guide to Physical Examination. Focus on the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and nails. Note: To access the online resources included with the text, you need to complete the FREE online registration that is located at https://evolve.elsevier.com/cs/product/9780323172660?role=student . To Register to View the Content Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student Enter the name of the textbook, Seidels Guide to Physical Examination (name of text without the edition number) in the Search textbox. Complete the registration process. To View the Content for this Text Go to https://evolve.elsevier.com/ Click on Student Site. Type in your username and password. Click on the Login button. Click on the plus sign icon for Resources on the left side of the screen. Click on the name of the textbook for this course. Expand the menu on the left to locate all the chapters. Navigate to the desired content (checklists, videos, animations, etc.). Note: Clicking on the URLs in the APA citations for the Resources from the textbook will not link directly to the desired online content. Use the online menu to navigate to the desired content. Suturing Tutorials The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques Tulane Center for Advanced Medical Simulation & Team Training. (2010, July 8). Suturing technique [Video file]. Retrieved from https://www.youtube.com/watch?v=c-LDmCVtL0o Note: Approximate length of this media program is 5 minutes. Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical mattress, horizontal mattress [Video file]. Retrieved from https://www.youtube.com/watch?v=MFP90aQvEVM Note: Approximate length of this media program is 9 minutes. Incision and Drainage of an Abscess (a common procedure in primary care) New England Journal of Medicine (NEJM). (2013, September 30). NEJM abscess incision and drainage [Video file]. Retrieved from https://www.youtube.com/watch?v=MwgNdrA18fM&list=PL9UKTUFtRDcNq4--Vf2NYfUANEyObfeNm&index=8 Note: Approximate length of this media program is 10 minutes. Dermablade Use for Shave Biopsies Dermablade®. (2012, November 9). PersonnaBlades [Video file]. Retrieved from https://www.youtube.com/watch?v=D8u1Y18L9DQ Note: Approximate length of this media program is 5 minutes. Welcome to week 4 We are entering week 4. Students have 2 assignments due this week. You will choose a lesion to document the SOAP note and secondly, this week is our first Shadow Health Assignment. There are several student tips, how to upload the lab pass, etc. located in the course.  Regarding the SOAP notes, there is not enough information. I advise you to make up the information that is not there (ie. Health hx, social hx, etc). This will allow you to critically think as you develop the notes.   You need to know that the DCE score is not the only score that counts as your grade, it is only a portion of the grade. You must complete the documentation portion. Also, we have noted that in SH, the ROS is not located in the documentation portion but is located in the subjective data collection portion.  Remember to document as the SOAP order. I advise you to review my SOAP document send last week for guidance. Last week we engulfed in great conversation on the risks of our findings about growth, measurements, and nutrition of children and their families. As practitioners, it’s important to communicate professionally, ask the right questions, and guide families as they strive to have healthier and happy lives. This week we will begin to review assessments of body systems. Skin, Hair, and Nails will be covered. I encourage you to perform the assessment of Skin, Hair, and Nails so that you may be proficient with it for the overall assessment. You are able to access the check lists by enrolling into the evolve website in your resources.  You first assignment for this week is to be written in a SOAP Note format (NO NARRATIVES). There is a template/sample for you to follow posted in your announcements at the beginning of the semester. You will need to put in the missing information in the note (some may be made up ie meds, hx, parts of the ROS and PE).  In the Assessment/Plan, you will document your differential diagnoses as per the assignment. I will comment on your notes and if needed, send you an email if I need to help you with them more. Assignment 1: 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 weeks 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.Comprehensive 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= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? S= severity SUBJECTIVE 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 (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom: 1. Location 2. Quality 3. Quantity or severity 4. Timing, including onset, duration, and frequency 5. Setting in which it occurs 6. Factors that have aggravated or relieved the symptom 7. Associated 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. Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors. Past Surgical History (PSH): Include dates, indications, and types of operations. Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function. 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. Immunization History: Include last Tdp, Flu, pneumonia, etc. Significant Family History: Include history of parents, Grandparents, siblings, and children. Lifestyle: Include cultural factors, economic factors, safety, and support systems. 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. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text. General: 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: Include rashes, lumps, sores, itching, dryness, changes, etc. HematologComprehensive 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): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three 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 returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over the counter Ibuprofen 200mg -2 PO as needed 6.) Over the counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs - rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: Heterosexual G1P1A0 Non-menstrating – TAH 1998 Personal/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 1 daughter, in her 50’s, healthy, living in nearby neighborhood. Lifestyle: She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She 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 and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends. Review of Systems: General: + fatigue sWeek 4 Lab Assignment: Differential Diagnosis for Skin Conditions 1: 2: 3. 4. 5. Page 5 of 5