Week 4-NURS 6512- Health Assessment

HPI: The patient is a 16-year-old Caucasian male. He presents to the clinic with an increased number of lesions surrounding virtually his whole body. B. K reports that the lesions started to develop 3 days ago. The lesions breakout all over the client’s body. He notes that he wakes up to red itchy rashes on the chest, face, scalp and back. He also says that there are also some few rashes on the legs and arms. The entire body has about 700 to 100 lesions which are red and painful. The pain can be rated as 6 on a scale of 1 to 10. The patient states that the lesions fill up with clear fluid quickly and burst making them appear crusty. B. K is also experiencing a low grade fever of 102°F. He has fatigue, sore throat, headache and has lost his appetite.

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Current Medications:

Colloidal Oatmeal Baths twice a day relieves pain and itching

Calamine Lotion. Relieves itching through application of the lesion affected areas

Benedryl antihistamine 25-50 mg PO q4-6hr; reduces itching, headache and fever

Allergies:  the client reports no known allergies  

PMHx: client had his last chickenpox vaccination lastly 5 years ago. His other immunizations are up to date. He reports no major surgeries. He has suffered acne at the age of 11 years. He was treated it completely by the time he was 12 years.Week 4-NURS 6512- Health Assessment

Soc Hx:  He is a high school student. He is negative for tobacco smoking and substance abuse. Denies the use of ETOH. The client spends his leisure time playing video games and football with his brother and friends at home. His mother works in town as a cashier for a bank. His parents are married for the last 10 years.

Fam Hx: The clients Mother suffered acne at the age of 21 years. She also has chronic acne. The younger brother ad chicken pox two weeks ago. His mother had chicken pox at 15 years. In his childhood, his father was also infected with chickenpox.

ROS:

GENERAL:  Positive for loss of weight since the start of the illness. positive for chills and fever, tiredness and weakness. There is an intense feel compelling the client to scratch the lesions.

HEENT:  Oral ulcers, skin lesions, pallor, cervical lymph nodes

SKIN:  skin lesions include papules, pustules, crusts and vesicles; itching; pruritic macules on the extremities, scalp abdomen, face, chest and back.

CARDIOVASCULAR: Normal S1 and S2 are heard. No chest pain, palpitations or edema; no chest pressure or discomfort.

RESPIRATORY:  Normal breathing sounds; no sputum, cough or shortness of breath

GASTROINTESTINAL:  No organomegaly; no abdominal tenderness; abdomen is symmetrical without distention; normal abdominal sounds heard

GENITOURINARY: positive for itching and lesions present

NEUROLOGICAL: no focal neurological deficits, No headache. MUSCULOSKELETAL:   positive for fatigue, joint pain, stiffness and muscle pain present.

HEMATOLOGIC: Bruising is evident from lesions; fluid filled lesions, no bleeding; no anemia.

LYMPHATICS:  Enlarged lymph nodes. No history of splenectomy.

PSYCHIATRIC:  Anxiety and depression history positive.

ENDOCRINOLOGIC: positive to sweating, cold and heat intolerance.

ALLERGIES:  No history of asthma, hives, eczema. Previous acne reported

O.

Physical exam: Vital signs: RR. 16, P 70, Tachycardia, low grade fever, B/P 101/73, Wt: 100 lbs; Ht: 4’9; BMI 21.6

Mental: discomfort due to fever and headache

Heart: pulses+2 bilat pedal and +2 radia

Skin/Lymph Nodes: rashes, lesions, papules, crust, vesicles

Genital:  positive for reddish and itchy external genitalia from the developing rashes, lesions and papules. Negative for genitalia tenderness

Diagnostic results:

1. Physical assessment and medical history of blisters
2. Antibody testing: to rule out the presence of underlying infection. This is indicated by the presence of IgG and IgM antibodies
3. PCR: It investigates resistance of VZV to acyclovir.
4. Chest X-ray; rules out the presence of pneumonia
5. Blood test:
6. Lesion culture
7. Chest X-ray: calcific lung lesions negative
8. Microscopic examination:  According to Ahmad et al. (2018), observation of intranuclear inclusions which are released by varicella virus indicates the presence of chickenpox.

A.

Differential Diagnoses

Chicken pox: This illness is caused by varicella-zoster virus. It is characterized by red, itchy rash that breaks out on the chest, back, scalp and face. The lesions can also develop to a lesser extent on the legs and arms. The chickenpox lesions form spots that fill up quickly with a clear fluid. They burst and become crusty on pressing. The rashes associated with this disease develop in clusters with the onset of raised red spots which progress into blisters filled with clear liquid. Generally, they appear like water drops on the red skin. Often, the blisters develop dimples in the middle and they break and heal or form sores that dry up forming crusts or scabs. Chickenpox is highly contagious and is spread through respiratory droplets from sneezes or coughs, saliva, contact with contaminated surfaces, skin and mother to child through pregnancy, nursing or labor.

2. Disseminated herpes simplex virus: This illness is linked to the presence of multiple lesions on skin regions or internal viscera. Patients often present with widespread eruption or erosions of pustules or vesicles. Regional Lymphadenopathy and fever are also associated factors. This disease indicates a compromised immune system and suggests the presence of other underlying infections. Its incubation period is 4 days after exposure and can range from 2 to 12 days.
3. Measles: This disease is highly contagious and has an incubation period of 10 to 14 days after exposure. Its signs and symptoms include fever, sore throat, red blotchy rash, inflamed eyes, runny nose and cough. It is spread through respiratory droplets, mother to child, skin contact and contaminates surfaces as well as saliva. It presents with widespread rash on the body which begins from the head. It is caused by a virus from the paramyxovirus family which invades the host cells and completes its lifecycle using the hosts cellular components.

Diagnosis

The appropriate diagnosis for the client is chickenpox. The client’s family members had the illness recently. He also demonstrates all the associated clinical manifestations of chickenpox.

References

Ahmad, U., Shaukat, A., Aamir, H., Ismail, U., & Ahmed, A. (2018). ARDS in Chicken Pox Pneumonia; Is Co Morbidity Really a Contributing Factor?. Annals of Punjab Medical College, 12(4).

Assignment 1: Lab Assignment: 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 Lab 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

• 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.Week 4-NURS 6512- Health Assessment
• 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 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 three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

This week you will be submitting your paper in SOAP format.  The template and the grading rubric for this format is located in the Course Info folder.  This is the format approved for this course, so please follow it.  You will be choosing one skin graphic to write your SOAP note.  need to organize your data in this format…..and under “S” you will need to ask your questions…but obviously your patient cannot answer you.  So….under “S”….list all of the questions that you would ask the patient from the template list, including Meds, Allergies, ROS, etc…….think about everything that you would need to know and ask to make a clinical decision.  The “O” is what the condition looks like.  This is the objective piece of the note…..you do not ask the patient questions here, it is just what you observe.    Be specific!!!  Describe the lesion ie:  size, location, characteristics, etc….  think of this as documenting directly in a patient’s chart.  A/P are your list of differentials with rationale on why you chose those diagnosis.  You list them from most likely to least likely.

In most cases, you will need to “create” information for each section…..for example, create a health history or background of the condition, or it is acceptable to list the information that you would want to know.  For this week, your “O” will be the description of the lesion that you chose.  You will then choose at least 3 differential diagnosis for this condition, starting with the most likely to least likely.  Support these differentials with scholarly references.
A common mistake that students make in writing SOAP notes is confusing the S and the O.  Remember….the S is what you ask the patient, and the O is only the exam portion of the exam and what you observe.

3. APA……for the most part, everyone is doing a great job with this.  If you are being deducted points, it is due to missing information, or inaccurate formatting of the information.  I know that Blackboard is not user friendly with indenting, etc…. so I am not deducting for those types of issues.  I have heard from some of you regarding how to site websites, etc…  If you have questions, please ask, but if not….please utilize the resources that I have outlined in the weekly updates.  We are utilizing the APA 7^thedition now

SUBJECTIVE DATA:

Chief Complaint (CC): Coughing up phlegm and fever

History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

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Medications:

• Lisinopril 10mg daily
• Combivent 2 puffs every 6 hours as needed
• Serovent daily
• Salmeterol daily
• Over the counter Ibuprofen 200mg -2 PO as needed
• Over the counter Benefiber
• Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs – rash

 Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet on no medication

4.) Osteopenia

5.) Allergic rhinitis

Past Surgical History (PSH):

• Cholecystectomy 1994
• Total abdominal hysterectomy (TAH) 1998

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstrating – TAH 1998

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.Week 4-NURS 6512- Health Assessment

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

 Significant Family History:

Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.

 Lifestyle:

She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She 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; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.

Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

CV: no 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: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.

MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.

Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: no endocrine symptoms or hormone therapies.

Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

OBJECTIVE DATA

 Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21 Week 4-NURS 6512- Health Assessment

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

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

ASSESSMENT:

 Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

 Diagnostics:

Lab:

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

 Differential Diagnosis (DDx):

• Acute Bronchitis
• Pulmonary Embolis
• Lung Cancer

 Diagnoses/Client Problems:

 .) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40 pack year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet on no current medication

 PLAN: [This section is not required for the assignments in this course, but will be required for future courses.] Week 4-NURS 6512- Health Assessment