• 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.

ComprehensiveSOAP 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.

Hematologic:

Endocrine:

Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI.

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 conscience, and affect and reactions to people and things.

HEENT:

Neck:

Chest/Lungs: Always include this in your PE.

Heart/Peripheral Vascular: Always include the heart in your PE.

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. 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 nonpharmacological 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?

© 2019 Walden University Page 2 of 3

ComprehensiveSOAP Template

Patient Initials: __AM_ Age: _____38_ Gender: ___F_

SUBJECTIVE DATA:

Slide No 3

Chief Complaint (CC):

Patient present with multiple lesions on he left thigh that been present for several weeks, approximately 3 months

.

History of Present Illness (HPI):

AM is a 38 years old Caucasian female presented to the clinic with multiple lesions on her left shoulder. Patient reported that lesion has been presents for about 2-3 months. Per patient, “I noticed like a nodule about 3 months ago now it’s about 4 nodules”. The lesion is palpable elevation which appears to be solid, firm and painless on examination. The nodules dimples in the middle when touched. Patient denies pains but says it could be painful when knocked. The nodules are about 5mm above the skin. Patient could not ascertain if nodules has increased in size. Pt is worried that it could be tumors or cancer. Pt has a family history of cancers or tumors.

Medications:

1.

Nifedipine XL30mg by mouth daily for Hypertension

2. Lipitor 10 mg by mouth once daily at bedtime for high cholesterol

Allergies:

Medication allergies- Penicillin react with Hives

Denies food allergies or latex allergue

Past Medical History (PMH):

1.

Primary Hypertension: diagnosed at age 28

2. Hyperlipidemia: diagnosed at age 30- control with medication, diet and exercise

Past Surgical History (PSH):

1.

Cesarean sections- 2007 for her second pregnancy

2. Cholecystectomy – 2015

Sexual/Reproductive History:

Patient is sexually active. She is not currently any birth control, says husband uses condom. Patient has regular (28 days) menstrual cycle. She is married with 2 children.

Personal/Social History:

Patient denies alcohol and illicit drug use. Never a smoker. She is active around the house and tried to eat healthy. Patient is a case manager and lives in a rented apartment. Patient is married with 2 children (a boy 18 and a girl 13). She takes a brisk walk of about 30 minutes every day after work.

Immunization History:

Patient believes to be up to date on immunization. Patient received flu vaccine September 2019.

Significant Family History:

Patient’s father is deceased, died of heart attack in 2011 at age 62. Mother (68) is still alive with medical history of obesity, hyperlipidemia, hypertension and type 11 diabetes. Patient has a brother with medical history of Hypertension. Paternal grand father died of skin cancer

Lifestyle:

She is Christian and believes in God. She attends a catholic church every Sunday Mass as

well as midweek mass.

Review of Systems:

General: Ms AM is alert and oriented. Calm and cooperative. Ms. AM endorsed recent weight lost and general body weakness sometimes.

HEENT:

Pt denies headache, dizziness, Pt denies any visual impairment, but wears glasses for near sightedness, no blurry vision, had her last eye exam a month ago (02/19/2020), no floaters. No difficulty in earing, no ringing in the ear, denies hearing loss. No ear infection, no ear pain or discharge. No nasal pain or drainage. No nose bleeds. Denies tooth pain/ache, No dental carries, No sore throat, denies painful/ difficulty in swallowing, denies mouth sores. No loose tooth, last dental visit (01/20/2020),

Neck:

Fullness in range of motion. No thyromegaly. No carotid bruits. No masses palpated. No tracheal deviation noted

Breasts:

Breast is symmetric. Negative to dimples

Respiratory:

. No dyspnea, tachypnea or hypopnea observed. Denies night sweat, wheezing, prolong cough. No hematemesis. Pt denies respiratory complaint.

CV:

No abnormal heart sound heard. Palpable peripheral pulses. Symmetric pulse volume. Good capillary refill. No peripheral tenderness or edema. No negative to chest pain. Pt is positive to hypertension. Electrocardiogram is normal sinus rhythm.

GI:

Audible bowel sounds. Denies pain or tenderness. No ascites observed. No abdominal Ulcer. Denies nausea or vomiting. No dysphagia, No hematemesis. No constipation. No diarrhea. Endorse loss of appetite lately. No heartburn or indigestion.

GU:

Negative to dysuria, no blood in urine. No urgency or increase in frequency of urination. Positive to polyuria, negative to vaginal discharge. Negative to dyspareunia. Negative for hemorrhoid.

MS:

Negative to joint pain. Swollen left axillary lymph node. Positive to fatigue and body weakness. Steady gait. Overweight.

Psych:

Positive self-esteem. Negative for suicidal ideation or homicidal ideation. Negative for hallucinations and grandiosity. Positive for mild anxiety as a result of nodules on the left arm.

Neuro:

No headache, dizziness, no numbness or tingling sensation. No loss of balance. Negative for tremors

Integument/Heme/Lymph:

She has a solid, firm and painless lesion on the left arm.

Endocrine:

Negative for polydipsia, polyphagia. Positive for polyuria.

.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Blood pressure 145/86 on the left arm, lying, pulse 84 and regular; Temperature 97.8 orally; RR 18 non-labored; oxygen saturation 99% at room air, weight: 264 pounds; height: 5’ 5”; and blood glucose 140 at 2 hours post pandial

General: Pt i alert and oriented to time, place, and person. Pt is calm and cooperative

HEENT: PERRLA; head is normocephalic, pupil is reactive to light. accommodation, speech

Neck: Carotids no bruit,

Chest/Lungs: Bilateral lung sound heard. Quiet rhythmic and effortless respiration. Full Symmetric respiratory effort. Chest is symmetric respiration is even,

ABD: soft non tender

Genital/Rectal: bowel sound heard on all quadrant, no ascites.

Musculoskeletal: strong

Neuro: intact

Skin/Lymph Nodes: skin is warm to touch. Axillary lymph nodes palpated.

ASSESSMENT:

Lab Tests and Results:

SAO2 – 99%

Diagnostics:

Labs: CBC with differential, CMP

Radiology: Chest x-ray

EKG:

Differential Diagnosis (DDx):

Cherry Angioma

Glomeruloid hemagiona

Angikeratoma corporis diffusum

Cherry angioma- Cherry angioma (CA) is the most common type of acquired benign vascular proliferation which usually presents as non-blanching red papules on the acral and truncal areas (Darjani, et al., 2018). CA has been seen in 2% of children, 50%ofadults, and 50%–75% of people aged older than 75 years old (Darjani, et al.,)

2.) Glomeruloid hemangioma- A small, firm, red dome-shaped papules subcutaneous bluish compressible tumors, wine-red pedunculated papules. They range in size, measuring few millimeters to few centimeters in diameter, and are located mainly on the trunk and proximal limbs and is characterized by a solitary or multiple blue-red papule (Gupta, Kandhari, Ramesh, and Singh, 2013).

3.) Angiokeratoma corporis diffusum- Angiokeratomas are hyperkeratotic papules that are characterized histologically by superficial ectatic vessels with epidermal proliferation. Red to purple, hyperkeratotic and coalescing papules, occurs most typically on the lower region of the trunk, buttocks, and thighs and is usually associated with Lyosomal storage diseases (Jayavardhana, Balasubramanian, and Vijayalakshmi, 2015).

Diagnoses/Client Problems of Image #2:

1.) Cherry angioma

2.) Hypertension

3.) Hyperlipidemia

.

References

Darjani, A., Rafiei, R., Shafaei, S., Rafiei, E., Eftekhari, H., Alizade, N., … Najirad, S. (2018). Evaluation of Lipid Profile in Patients with Cherry Angioma: A Case-Control Study in Guilan, Iran. Dermatology Research & Practice, 1–5. https://doi-org.ezp.waldenulibrary.org/10.1155/2018/4639248

Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid hemangioma in normal individuals. Indian Journal Of Dermatology, 58(2), 160. doi:10.4103/0019-5154.108088

Jayavardhana, A., Balasubramanian, P., & Vijayalakshmi, A. M. (2015). Angiokeratoma corporis diffusum. Indian Pediatrics, 52(2), 175. Retrieved from Walden Library database

© 2019 Walden University Page 2 of 3

8-2

Key Points

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Ball: Seidel’s Guide to Physical Examination, 8th Edition

Chapter
08
:
Skin, Hair, and Nails

Key Points

This review discusses examination of the skin, hair, and nails.

Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass or dermatoscope; and Wood’s lamp.

To examine the skin, perform the following.

Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.
During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.

Inspect the skin in two ways.
First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences among body areas, and compare sun-exposed areas with areas that were not exposed to the sun.
Second, observe the skin as each part of the body is examined.
When evaluating the skin and mucous membranes in each part of the body, note six characteristics.
The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.
The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.
The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is at areas of pressure or rubbing, such as the elbows, soles, and palms.
The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.
The fifth characteristic is hygiene, which may contribute to skin condition.
The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.
During inspection, also palpate the skin to determine five characteristics.
First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.
Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm but should be bilaterally symmetrical.
Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.
Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.
If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined.

First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.
If the lesion has exudates, note their color, odor, amount, and consistency.
If there is more than one lesion, describe their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.
Record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.
Use a light and magnifying glass to determine the lesion’s subtle details, including color, elevation, and borders.
To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.
To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection.

To
examine the hair, perform the following.
To assess the hair, palpate its texture. Scalp hair may be coarse or fine and curly or straight. It should be shiny, smooth, and resilient.
During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.
Hair color ranges from very light blond to black to gray.
Hair distribution and quantity vary with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.

To examine the nails, perform the following.
Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.

Inspect the nails for six characteristics: color, length, condition, configuration, symmetry, and cleanliness.
Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.
The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.
In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.
The nails should appear bilaterally symmetrical.
The nails should be clean, smooth, and neat.

Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.
The nail-base angle should measure 160 degrees.
If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.
Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.

Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.
The texture of the nail plate should be hard and smooth.
The nail base should be firm—not boggy.
The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.
The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad.

Week 4 Lab Assignment:
Differential Diagnosis for Skin Conditions

1:

2:

3.

4.

5.

�Note to Build: These images are still pending permissions so I don’t have credit lines yet or approval.

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