- 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.
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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 / Lab Tests and results:
ASSESSMENT
Differential diagnosis 1:
Differential diagnosis 2:
Differential diagnosis 3:
Differential diagnosis 4:
Differential diagnosis 5:
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Rubric for grading and Reference lists
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.
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. = The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.
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. = The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
Written 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. = Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Written Expression and Formatti
1
Lab Assignment: Differential Diagnosis for Skin Conditions
Student??s Name
Institutional Affiliation
Course
Date
2
Lab Assignment: Differential Diagnosis for Skin Conditions
Purpose: This paper aims to perform a differential diagnosis of a skin condition depicted in
graphic no. 4. Through objective assessment, the paper records observations and analyses them
to come up with a differential diagnosis as per the SOAP format.
Week 4: Skin Comprehensive SOAP Note
Patient Initials: __H.K___Age: __45_____Gender __M____
Subjective Data
Chief Complaint (CC): Redness, pain, and swelling of the skin on the left leg, fever.
History of Present Illness (HPI): H.K. is a 45-year-old Caucasian male who reports fever and
severe soreness, swelling, and redness of the skin on the left leg. The patient also complains of
3
fever before the discovery of erythema on the leg, which spread over a larger skin area with time.
The patient also reported hitting his leg on a hard surface during his regular plumbing work
schedule. The accident did not lead to an open wound immediately, and there was no bruising or
broken skin. Also, he did not take any medications for the fever but applied first aid by placing
ice on the hit area once the pain progressed. The patient denied any use of painkillers or
application of any form of cream.
Medications:
i. Inderal 120 mg extended release, orally, daily
ii. Losartan 100 mg, orally, daily
iii. Bumex 3 mg, twice a day
iv. Protonix 20 mg, orally, daily
v. Coreg 25 mg, orally, twice a day
vi. Hydralazine 100 mg, thrice a day
vii. Lantus 12 units taken subcutaneously
viii. Citalopram 40 mg, orally, every day
vi. Insulin a part, administered bedtime subcutaneously after every meal
vii. Lipitor 80 mg, orally, every day
Allergies:
The patient reports an allergic response to Tetracycline Adhesive.
Past Medical History:
4
i. Hypertension
ii. Depression
iii. Morbid obesity Diabetes Mellitus
iv. Gastro-esophageal reflux disease (GERD)
v. Hyperlipidemia
Past Surgical History (PSH):
i. Right shoulder arthroscopy
ii. Laser eye surgery in 2018
Sexual/Reproductive History: heterosexual, sexually active.
Personal/Social History: The patient reports smoking cigarettes about five years ago but
managed to quit. He takes alcohol-based drinks with a friend, especially on weekends. He denied
the use of any narcotic drugs throughout his life. His hobbies include playing chess, and
draughts, riding m motorcycle, partici
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