Skin Conditions Assignment Paper

Skin Conditions Assignment Paper

Chief Complaint (CC): protruding mass for over one year
History of Present Illness (HPI): R.K is a 65 years old male who presents with a protruding skin mass that was of gradual onset at the trunk region for over one year. The mass is painless unless inflamed or irritated and increases in size gradually despite taking steroids. No aggravating, relieving, and associating factors. The patient is known to have diabetes mellitus and hypertension.
Medications: Currently the patient is on glucomet 500mg twice a day, nogluc 5mg once a day, atorvastatin 40mg at night, hydrochlorothiazide 25mg once a day, and amlodipine 10mg once a day.
Allergies: R.K reports being allergic to dust and pets. No known food or drug allergy.
Past Medical History (PMH): the patient was previously admitted in hospital due to hyperglycemia, hypertension, and hypercholesterolemia. He is known to have diabetes type two, hypertension, and obesity. He denies a history of blood transfusion and engaging in careless sexual intercourse.
Past Surgical History (PSH): the patient has not undergone minor or major surgical procedures.

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Personal/Social History: R.K is married and stays with his wife and two children. He works as a packaging manager at a flour millers company. He takes alcohol occasionally and smokes tobacco regularly. He prefers eating junk to healthy foods and rarely engages in physical exercise. He cleans his face once every morning and applies cosmetic creams.
Immunization History: His immunization schedule is up to date
Significant Family History: his parents and siblings are alive and healthy. There is no history of chronic illnesses in the family.
OBJECTIVE DATA:
The patient is in a fair general condition with a skin lesion 2cm by 2 cm at the trunk region. The skin tag has normal skin color with no hyper-pigmented skin surrounding. He is well-groomed for the weather and is well oriented to timing and place. The surrounding skin is reddish and warm. However, the patient is not pale, dehydrated, cyanosed, and jaundiced. The patient’s temperature is at 36.6 degrees Celsius, blood pressure at 134/84 mmHg, BMI AT 34.2, the pulse rate at 78beats per cycle, and oxygen circulation at 98% room air.
ASSESSMENT:
Differential diagnoses are skin tag, pedunculated seborrheic keratosis, and nodular melanoma.
Pedunculated seborrheic keratosis is a skin condition that results from clonal expansion of the mutated epidermal keratinocyte. It presents with a skin lesion that is itch and painful but less than 1cm in size (Minagawa, A. 2017). A skin tag is a skin disease that presents with a non-painful and itchy lesion. It commonly affects diabetic, hypertensive, and obese patients (Koyuncu, et al, 2018). Nodular melanoma is a skin condition that presents with a hypopigmented or hyperpigmented lesion that grows and spreads quickly.
Diagnostic Investigations:
Fine needle aspirate test will rule out malignant skin lesions, Ultrasound scan, Biopsy for histopathology to rule out malignancies, Erythrocytic sedimentation rate to determine inflammatory processes in the body, Blood sugar level (random and fasting) to determine the glycemic control, Lipid profile to determine the cholesterol and triglyceride levels, and Kidney function test.
Reflection
The experience of clerking a patient with a skin disease is quite challenging because the patient cannot tell the specific duration of the skin illness. However, it enlightened about skin diseases associated with lifestyle diseases.

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. Skin Conditions Assignment Paper

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. Skin Conditions Assignment Paper

 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. Skin Conditions Assignment Paper

            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.

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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. Skin Conditions Assignment Paper

 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. Skin Conditions Assignment Paper

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?

 References
Koyuncu, B. U., Karaca, M., Sari, F., & Sari, R. (2018). Is Skin Tag Associated with Diabetic Macro and Microangiopathy?. Journal of the National Medical Association, 110(6), 574-578.
Minagawa, A. (2017). Dermoscopy–pathology relationship in seborrheic keratosis. The Journal of dermatology, 44(5), 518-524. Skin Conditions Assignment Paper