Skin
· Choose one skin condition graphic (identify by number in your Chief Complaint)Number 5 please follow the sample SOAP 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.
Please follow the sample notes but work can’t be equal – make up different information
NURS 6512N
Advanced Health Assessment
Walden University
Week 4Assignment
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SOAP NOTE
Differential Diagnosis for Skin Condition
Skin Condition Picture #5
Patient Initials: AP Age: 69 Gender: M
SUBJECTIVE DATA:
Chief Complaint (CC): Complains of rash that have some blisters and scab on the chest and
back.
History of Present Illness (HPI): Mike Jones is a 69-years old Caucasian male who presents
today with a new onset of clusters of rash and blisters on his anterior, right flank and posterior
chest. He reports that 4 days prior to the rash appearing he had itching, tingling, burning and pain
in the same area of the rash. He reports the severity of pain 7/10 and 10/10 with palpation.
Medications:
1. Tamsulosin (Flomax) 0.4 mg for BPH
2. Over the counter Aspirin 81 mg daily
3. Over the counter Benadryl 25mg 1 tab every 6 hours for itching.
4. Over-the-counter topical hydrocortisone cream for itching as needed.
5. Over-the-counter Tylenol extra strength two tablets every 6 hours for pain.
Allergies: No Know Drug Allergies
Past Medical History (PMH):
1. Benign prostatic hyperplasia – age 50
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2. History of gallstone- age 45
3. Chickenpox – age 6
4. Chlamydia-age 25
Past Surgical History (PSH):
1. Cholecystectomy 2010-age 59
2. Transurethral resection of the prostate 2012 – age 61
Sexual/Reproductive History:
Heterosexual
Personal/Social History: Past tobacco product use, quit more than 30 years ago, denies ETOH,
or illicit drug use. He enjoys fishing and camping with his friends and visiting with his children
and grandchildren as often as he can. He drinks an occasional glass of wine or beer at social
gathering.
Immunization History: His immunizations are up to date. Patient last Influenza vaccine was
two weeks ago. Received the pneumococcal vaccine at age 65. Believe all childhood vaccination
was received. Last Tdap received when he was in college.
Significant Family History:
Natural death- Mother-deceased at age 90.
Gout, hemorrhagic stroke, hypertension, ETOH -Dad age 92.
Cervical Cancer- Maternal grandmother died at age 86.
Congestive heart failure, Asthma, COPD – Maternal grandfather- die at age 75.
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Drown-Paternal grandmother – deceased at age 35 in a boating accident
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.
© 2021 Walden University Page 2 of 3
Week 4 Lab Assignment:
Differential Diagnosis for Skin Conditions
1:
2:
3.
4.
5.
© 2021 Walden University
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