Tina Jones Health History
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 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.
Rubric
Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic.
Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
Comprehensive 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): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.
Medications:
Norvasc 10mg daily
Combivent 2 puffs every 6 hours as needed
Advair 500/50 daily
Singulair 10mg daily
Over the counter Tylenol 325mg as needed
Over the counter Benefiber
Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
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Past Surgical History (PSH):
Cholecystectomy 1994
Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.
He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or compression..
Breasts:. Denies history of lesions, masses or rashes.
Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.
CV: denies chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.
GI: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.
Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.
Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.
Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound
Genital/Rectal: pt declined for this exam
Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Diagnosis (DDx):
Asthmatic exacerbation, moderate
Pulmonary Embolism
Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
Section: NURS 6512N-47(08/28/2023-11/12/2023)
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include the history of parents, maternal/paternal Grandparents, siblings, and children):
Review of Systems: From head to toe, including each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information in this section is based on what the patient tells you. To ensure 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:
Hematologic:
Endocrine:
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Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): Right foot wound for two weeks
History of Present Illness (HPI): A 28-year-old African-American woman presents with a complaint of a non-healing wound on her right foot that happened after she suffered a fall two weeks ago. She reports that she twisted her right ankle and scraped her foot. She reports ankle swelling and a sharp, throbbing pain at the bottom of her foot. She grades the pain at a 7/10 and is worse with putting weight on the foot, whereby it becomes a 9/10. X-rays done at the emergency department were normal and she has been taking Tramadol 100mg once daily for the pain, which only slightly relieves the pain. The patient also reports the swelling on the ball of her foot has increased and her shoes do not fit. The wound is now very red and discharging pus, not foul smelling. She also reports a fever last night but no nausea or vomiting. She has been cleaning and dressing the wound two times daily. She has had type II diabetes since she was 24 years and is not compliant with her meds and does not monitor her blood sugar levels.
Medications: Tramadol 100mg OD for pain relief
Allergies: She is allergic to penicillin, which gives her rash, and cats/dust, which causes runny nose, eye swelling, and itch, and exacerbates her asthma
Past Medical History (PMH): She has type 2 diabetes not well managed, and has asthma, which is well-controlled with an albuterol inhaler two times a week.
Past Surgical History (PSH): No history of prior surgeries
Sexual/Reproductive History: She attained menarche at 11 years and has regular menses, her first sexual encounter was at 18 years. She is currently not having sex with anyone and is not on any contraceptives. Not been tested for STDs recently. She is not dating right now but hopes to have children in the future.
Personal/Social History: She is the firstborn in a family of three children. She is currently living with her mother and younger sister in their family home. She is employed and is a part-time student pursuing a degree in accounting. She reports a good relationship with her family members and friends. Her father died recently in a MVA but she has been coping well with the support of her family and friends. She denies any history of tobacco use but smoked cannabis since she was 15 and quit at 21. No illicit drug use but she drinks alcohol about 3 times a month.
Immunization History: She received all the recommended childhood vaccinations, has been fully vaccinated against COVID, and receives occasional buster shots. She received meningococcal vaccine when she was in college
Health Maintenance: She does not exercise and does not maintain a healthy diet for a diabetic patient. Her daily diet consists of a sandwich for lunch, a chicken for dinner, and snacks like fries and pretzels. She wears a seatbelt when driving and has a gun, which she locks in a safe
Significant Family History (Include a history of parents, maternal/paternal Grandparents, siblings, and children):
Mother, 50 has high blood pressure and high cholesterol
Father had type II diabetes and hypertension
Paternal grandfather died of colon cancer at 65, paternal grandmother is 82 and has hypertension
Maternal grandmother died of a stroke at 73, also had hypertension and high cholesterol
The Sister has asthma, the brother is overweight
Review of Systems:
General: She reports a fever and unintentional weight loss of 10 lbs over the past month despite increased appetite. No changes in diet or level of activity
HEENT: No headaches, no earaches, no eye swelling, or redness, no nasal discharge, no sore throat
Neck: No neck swelling or tenderness
Breasts: No lumps, no pain, no nipple discharge
Respiratory: She reports no cough, no wheezing, and no difficulty in breathing
Cardiovascular/Peripheral Vascular: No palpitations
Gastrointestinal: No diarrhea, no constipation, no nausea, no vomiting
Genitourinary: No painful urination, no blood in urine
Musculoskeletal: Reports a painful wound on her right foot, but no joint pains or muscle aches
Psychiatric: No history of mental illness
Neurological: No headaches, no dizziness, or blurry vision
Skin: She reports acne, dry skin, and darker skin on her neck, also has excess hair on her body and face
Hematologic: She denies easy bruising or bleeding
Endocrine: No excessive sweating or thirst
OBJECTIVE
General: A young African-American woman, seated upright on the exam table, seems to be in a fair general condition, not in any obvious distress, and is obese.
HEENT: No bruises or contusion, no bleeding, no eye redness, swelling, or discharge, no ear discharge, nasal septum is midline, no rhinorrhea, no erythema or swelling of the tonsils
Local exam of the foot: There is a wound on the heel of the right foot, measuring 2cm by 1.5cm and 2.5 mm in depth. It has red edges and the surrounding skin is erythematous but no edema or tracking. The wound is draining a serosanguinous fluid.
Cardiovascular: S1 S2 heard, no murmurs, rubs, or gallops
Respiratory: Bilateral chest wall expansion with respiration, percussion note is resonant, vesicular breath sounds on auscultation
ASSESSMENT
Diagnosis: Diabetic foot ulcer- This is a common complication in patients with poorly controlled diabetes mellitus. It can be a result of poor glycemic control like in con-compliant patients, neuropathies, or injuries such as trauma or wearing ill-fitting shoes (Oliver & Mutluoglu, 2022). Diabetic ulcers are more common in pressure areas like the soles or balls of the feet with a punched-out appearance, such as in this patient. The ulcer is usually painless but may become painful when infected. The patient reports to have tripped and hurt her foot after which the wound did not heal. She is also a known diabetic patient and has not been on medication for three years now. These factors increase her chances of getting a diabetic ulcer (Wang et al., 2022).
Differential diagnoses:
Acute osteomyelitis- This is an infection of the bone that can occur either directly by bacterial inoculation through puncture wounds or by hematogenous spread. The symptoms typically present two weeks after the infection and include fever, swelling, pain, hotness, and redness over the affected area (Dobaria & Cohen, 2023).
Blunt trauma- trauma over a bone due to a fall may become infected and form a wound that presents with pain and tenderness over the affected area.
Thrombophlebitis- Trauma can also cause inflammation of the superficial veins leading to pain and tenderness (Czysz & Higbee, 2022).
Diagnostic tests:
Do a random blood sugar and hemoglobin A1C levels to determine glycemic control. HbA1C will be higher than normal in patients with uncontrolled diabetes over a long duration.
Imaging studies include a repeat X-RAY and MRI to rule out osteomyelitis (Dobaria & Cohen, 2023).
A complete blood count with differentials to rule out an infection
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
References
Czysz, A., & Higbee, S. L. (2022, January 4). Superficial thrombophlebitis – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK556017/
Dobaria, D. G., & Cohen, H. L. (2023, August 6). Osteomyelitis imaging – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK594242/
Oliver, T. I., & Mutluoglu, M. (2022, May 10). Diabetic foot ulcer – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK537328/
Wang, X., Yuan, C., Xu, B., & Yu, Z. (2022). Diabetic foot ulcers: Classification, risk factors, and management. World Journal of Diabetes, 13(12), 1049-1065. https://doi.org/10.4239/wjd.v13.i12.1049