Differential Diagnosis Skin Conditions Paper
Differential Diagnosis Skin Conditions Paper
Differential Diagnosis for Skin Conditions
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 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 for Differential Diagnosis Skin Conditions Paper
- Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this 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.
- Download the SOAP Template found in this week’s Learning Resources.
To complete Differential Diagnosis Skin Conditions Paper
- 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 3 different references from current evidence based literature. Differential Diagnosis Skin Conditions Paper
Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. L =location O= onset C= character A= associated signs and symptoms T= timing E= exacerbating/relieving factors 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 (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale © 2014 Laureate Education, Inc. Page 1 of 3 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.
Identify if it is an allergy or intolerance. Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations. Past Surgical History (PSH): Include dates, indications, and types of operations. Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
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 Tdap, Flu, pneumonia, etc. Significant Family History: Include history of parents, grandparents, siblings, and children. Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference. 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). Differential Diagnosis Skin Conditions Paper.
Remember that the information you include in this section is based on what the patient tells you so 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: Hematologic: © 2014 Laureate Education, Inc. Page 2 of 3 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- only in this course. Differential Diagnosis Skin Conditions Paper.
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 consciousness, and affect and reactions to people and things. Differential Diagnosis Skin Conditions Paper
HEENT: Neck: Chest Lungs: Heart Peripheral Vascular: Abdomen: Genital/Rectal: Musculoskeletal: Neurological: Skin: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. Differential Diagnosis Skin Conditions Paper.
ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. 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. REFLECTION: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 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? © 2014 Laureate Education, Inc. Page 3 of 3 1