Differential Diagnosis for Skin Conditions Assignment

Differential Diagnosis for Skin Conditions Assignment

Week 4

Skin Comprehensive SOAP Note Template

 Patient Initials: L.S; Age: 32; Gender: Female

 SUBJECTIVE DATA:

 Chief Complaint (CC): “My leg is painful and swollen.” GRAPHIC 4

 History of Present Illness (HPI): L.S is a 32-year-old female who presented with chief complaints of having a painful and swollen leg. She states that the symptoms started after she fell and sustained a minor injury 5 days ago when hiking in the woods. She got pricked on the left leg by a stick, but she did not think it would result in a severe outcome. The patient states that the pain in the leg had gradually increased, and the swelling progressed every day. In addition, to the pain and swelling, she reports that the affected leg area is red and warmer than the other leg. The client also states that she has been having a mild fever in the past two days and is unsure whether it is associated with the leg injury. She has taken Tylenol in the past two days, but it has not been effective in alleviating the pain. She rates the pain as 5/10.

 Medications:  OTC Tylenol 3 tabs per day to relieve pain.

 Allergies: No allergies.

 Past Medical History (PMH): No history of chronic diseases. No admission history.

Past Surgical History (PSH): She had an I&D at 27 years due to an abscess on her right breast.

Sexual/Reproductive History: Para 2+0. LMP- 2 weeks ago. No history of gynecologic disorders or STIs.

 Personal/Social History: The patient was born and raised in Collier County, FL. She is married and has two children, 7 and 3 years. She studied up to undergraduate level and is a Travel consultant. Her hobbies include hiking and baking.

Health Maintenance: The patient attends annual health check-ups. She goes to the gym at least thrice a week. Sleeps 5-7 hours a day.

 Immunization History: Immunization is current. Last Influenza shot- 4 months ago; Last TT- 4 years ago.

Significant Family History: The mother has Stomach cancer, and the paternal grandfather has diabetes and succumbed to renal failure.

Review of Systems:

General: Reports mild fever. Negative for weight changes, chills, or fatigue.

HEENT: Denies eye pain, changes in vision, ear pain/discharge, hearing loss, rhinorrhea, epistaxis, or sore throat.

Respiratory: Negative for cough, chest pain, or wheezing.

Cardiovascular/Peripheral Vascular: Negative for dyspnea, palpitations, or exertional dyspnea.

Gastrointestinal: Denies nausea/vomiting, abdominal discomfort/pain, or bowel changes.

Genitourinary: Denies abnormal PV discharge or urinary symptoms.

Musculoskeletal: Denies joint pain/stiffness or muscle pain.

Neurological: Negative for muscle weakness, dizziness, headaches, or burning sensations.

Psychiatric: Negative for hx of mood or psychotic disorders.

Skin/hair/nails: Positive for erythema. Denies skin rash, bruises, hair loss, or discoloration of nails.

 OBJECTIVE DATA:

Physical Exam:

Vital signs: BP-114/72; HR-82; RR-16; Temp- 100.22F

General: Female patient in her early 30s. She is alert, oriented, and not in any distress. She maintains eye contact and has normal speech.

HEENT: Head: Symmetrical and atraumatic; Eyes: PERRLA; Ears: Transparent and shiny TMs; Nose; Symmetrical and midline. Each nostril is patent, Pink nasal mucosa; Throat: Tongue is pink and midline. The throat is pink and vascular without swelling, exudates, or lesions.

Neck: Symmetrical; Trachea is midline; Thyroid is normal on palpation.

Chest/Lungs: Clear on auscultation.

Heart/Peripheral Vascular: RRR; S1, and S2 present.

Abdomen: No tenderness, masses, or organomegaly.

Genital/Rectal: Normal female genitalia; No rectal fissures.

Musculoskeletal: Active ROM in all joints.

Neurological: Muscle strength-5/5; CNs- intact.

Skin: Erythema, tenderness, and warmth on the anterior lower part of the left leg.            Leg swelling.

 Diagnostic results:

Complete blood cell (CBC) count- Elevated WBCs

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ASSESSMENT:

1. Cellulitis
2. Necrotizing fasciitis
3. Erysipelas

Primary Diagnosis: Cellulitis

Cellulitis is characterized by non-necrotizing inflammation of the skin and subcutaneous tissue due to a primary infection. The inflammation is caused by skin invasion by various bacteria such as Streptococcus pneumonia, Staphylococcus aureus, and Vibrio vulnificus (Rrapi et al., 2021). It presents with four classic symptoms: pain, warmth, swelling, and erythema (Ortiz-Lazo et al., 2019; Sullivan & de Barra, 2018). Cellulitis is categorized as purulent and non-purulent, with the former having pus in the affected part. Patients with moderate to severe infection may have symptoms of fever, malaise, chills, hypotension, tachycardia, tachypnea, and toxicity (Brown & Hood Watson., 2021). Cellulitis is the primary diagnosis based on pertinent positive findings of pain, erythema, swelling, and warmth of the leg that sustained blunt trauma. The patient also presented with low-grade fever and elevated WBCs, indicating an underlying infection vulnificus (Rrapi et al., 2021).

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Brown, B. D., & Hood Watson, K. L. (2021). Cellulitis. In StatPearls. StatPearls Publishing.

Ortiz-Lazo, E., Arriagada-Egnen, C., Poehls, C., & Concha-Rogazy, M. (2019). An Update on the Treatment and Management of Cellulitis. Actualización en el abordaje y manejo de celulitis. Actas dermo-sifiliograficas, 110(2), 124–130. https://doi.org/10.1016/j.ad.2018.07.010

Rrapi, R., Chand, S., & Kroshinsky, D. (2021). Cellulitis: A Review of Pathogenesis, Diagnosis, and Management. Medical Clinics, 105(4), 723-735. https://doi.org/10.1016/j.mcna.2021.04.009

Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical medicine (London, England), 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160

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Asthma is a respiratory disorder that affects children and adults. Advanced practice nurses often provide treatment to patients with these disorders. Sometimes patients require immediate treatment, making it essential that you recognize and distinguish minor asthma symptoms from serious, life-threatening ones. Since symptoms and attacks are often induced by a trigger, advanced practice nurses must also help patients identify their triggers and recommend appropriate management options. Like many other disorders, there are various approaches to treating and managing care for asthmatic patients depending on individual patient factors.

One method that supports the clinical decision making of drug therapy plans for asthmatic patients is the stepwise approach, which you explore in this Assignment.

To Prepare:
Reflect on drugs used to treat asthmatic patients, including long-term control and quick relief treatment options for patients. Think about the impact these drugs might have on patients, including adults and children.
Consider how you might apply the stepwise approach to address the health needs of a patient in your practice.
Reflect on how stepwise management assists health care providers and patients in gaining and maintaining control of the disease.

By Day 7 of Week 3
Assignment:
Create a 5- to 6-slide PowerPoint presentation that can be used in a staff development meeting on presenting different approaches for implementing the stepwise approach for asthma treatment. Be sure to address the following:
Describe long-term control and quick relief treatment options for the asthma patient from your practice as well as the impact these drugs might have on your patient.
Explain the stepwise approach to asthma treatment and management for your patient.
Explain how stepwise management assists health care providers and patients in gaining and maintaining control of the disease. Be specific.