S.O.A.P Note Essay on Melanoma Assignment

S.O.A.P Note Essay on Melanoma Assignment

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:

• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Assignment. – For this assignment, the topic of choice is Melanoma. Please see this link for details on melanoma - https://www.visualdx.com/visualdx/diagnosis/melanoma?moduleId=101&diagnosisId=51936• 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. S.O.A.P Note Essay on Melanoma Assignment

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To complete:

• 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. S.O.A.P Note Essay on Melanoma Assignment. 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.

Comprehensive SOAP Exemplar

Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.

Patient Initials: _______ Age: _______ Gender: _______

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 3 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 it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. S.O.A.P Note Essay on Melanoma Assignment

Medications:

1.) Lisinopril 10mg daily

2.) Combivent 2 puffs every 6 hours as needed

3.) Serovent daily

4.) Salmeterol daily

5.) Over-the-counter Ibuprofen 200mg -2 PO as needed

6.) Over-the-counter Benefiber

7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs - rash

Past Medical History (PMH): S.O.A.P Note Essay on Melanoma Assignment

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and 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):

1.) Cholecystectomy 1994

2.) Total abdominal hysterectomy (TAH) 1998

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstruating – TAH 1998

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. S.O.A.P Note Essay on Melanoma Assignment

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 one daughter in her 30s, healthy, living in nearby neighborhood.

Lifestyle:

She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. S.O.A.P Note Essay on Melanoma Assignment

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 that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends. S.O.A.P Note Essay on Melanoma Assignment

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 a 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. S.O.A.P Note Essay on Melanoma Assignment

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. S.O.A.P Note Essay on Melanoma Assignment

GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs 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, headaches. 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: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago. S.O.A.P Note Essay on Melanoma Assignment

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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

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):

1.) Acute Bronchitis

2.) Pulmonary Embolis

3.) Lung Cancer

Diagnoses/Client Problems:

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40-pack-a-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.] S.O.A.P Note Essay on Melanoma Assignment

ADULT EXAMINATION CHECKLIST

Guide for Skin, Hair, and Nails

Check (✔) if normal, * if abnormal, Ø if absent

Subjective Data

Skin Hair ______ Eruptions ______ Use of dyes, permanents ______ Lesions/sores/rashes ______ Changes in: ______ Color changes ______ Amount ______ Texture changes ______ Texture ______ Bruising ______ Character ______ Infections ______ Hair loss ______ Birthmarks ______ Hair care: ______ Skin growths ______ Shampoo ______ Acne ______ Conditioner ______ Moles ______ Distribution ______ Itching ______ Body hair ______ Masses ______ Hair on head ______ Excessive sweating ______ Shaving ______ Skin care ______ Face

S.O.A.P Note Essay on Melanoma Assignment

______ Bathing ______ Axillary ______ Soaps ______ Legs ______ Lotions

______ Pigmentation changes or Nails discoloration ______ Changes in appearance

______ Splitting ______ Cracking ______ Peeling ______ Discoloration

______ Texture ______ Nail care

Detail those marked abnormal: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

S.O.A.P Note Essay on Melanoma Assignment

Objective Data: Inspection and Palpation

Skin Primary Lesions Configuration of Lesions ______ Grouped (clustered) ______ Macule (flat, < 1 cm) ______ Herpetiform (Zosteriform)—nerve ______ Patch (> 1 cm) ______ Linear (line) ______ Papule (palpable, < 1 cm) ______ Annular (circle) ______ Plaque (> 1 cm) ______ Polycyclic (multiple circles) ______ Nodule (solid, raised, deep, 1-2 cm) ______ Arciform (bow-shaped) ______ Tumor (2 cm) ______ Reticular (lesions meshed) ______ Vesicle (fluid-filled, < 1 cm) ______ Confluent (lesions merged) ______ Bulla (> 1 cm) ______ Discrete (individual) ______ Pustule (purulent vesicle/bulla) ______ Iris/target (concentric rings) ______ Wheal (cutaneous edema) ______ Gyrate (spiral) ______ Cyst (encapsulated)

Color of Lesions Secondary Lesions __________________________________ ______ Scale (loose surface epithelium) __________________________________ ______ Crust (dried surface fluids) __________________________________ ______ Excoriation (scratch)

______ Erosion (loss of epidermis) Description of Lesions ______ Scar __________________________________ ______ Ulcer (loss of epidermis, dermis) __________________________________ ______ Atrophy __________________________________ ______ Keloid (enlarged scar)

______ Fissure (crack) Texture and Firmness ______ Lichenification (thickened, with irrita- __________________________________ tion) __________________________________ __________________________________

Distribution __________________________________ __________________________________ __________________________________

S.O.A.P Note Essay on Melanoma Assignment

Vascular Lesions ______ Purpura (red/purple, > 0.5 cm) ______ Mongolian spots ______ Petechiae (< 0.5 cm) ______ Pattern injuries ______ Ecchymosis (bruise) Location ________________________ ______ Spider angioma ________________________________

(red body, radiating legs) ________________________________ ______ Venous star (blue spider, linear) ________________________________ ______ Telangiectasia ______ Dry skin

(dilated capillaries) Location ________________________ ______ Capillary hemangioma ________________________________

(red, irregular patches) ________________________________ ______ Cherry angioma ________________________________ ______ Strawberry angioma ______ Skin turgor ______ Port-wine stain ______ Tenting

______ < 2 sec Other Skin Lesions ______ 2-3 sec ______ Corn ______ 3-4 sec ______ Callus ______ > 4 sec ______ Cutaneous tag ______ Contact dermatitis

Other Skin Conditions Detail those marked abnormal: ______ Pallor ______________________________________

Location __________________ ______________________________________ __________________________ ______________________________________ __________________________ ______________________________________

______ Erythema ______________________________________ Location __________________ ______________________________________ __________________________ ______________________________________ __________________________ ______________________________________

______ Cyanosis Location __________________ Hair: Inspection and Palpation __________________________ ______ Texture _________________________ __________________________ ______ Color ___________________________

______ Jaundice ______ Distribution ______ Vitiligo Body ___________________________ ______ Location __________________ ________________________________

__________________________ Head ___________________________ __________________________ ________________________________

________________________________ ______ Clean shaven

Thickness _______________________ ________________________________

______ Dryness

S.O.A.P Note Essay on Melanoma Assignment

______ Inflammation Detail those marked abnormal: ______ Alopecia ______________________________________

____________________________ ______________________________________ ______________________________________

Nails: Inspection and Palpation ______________________________________ ______ Color _______________________ ______________________________________ ______ Length______________________ ______________________________________ ______ Clean ______________________________________ ______ Pigment deposits ______________________________________ ______ Bands ______________________________________ ______ Streaks ______________________________________ ______ Spots ______________________________________ ______ Smooth nail edges ______________________________________ ______ Ridging ______________________________________ ______ Grooves ______________________________________ ______ Pitting ______________________________________ ______ Curved, smooth nail plate ______________________________________ ______ Nail base angle—160 degrees ______________________________________ ______ Adheres to nail bed ______________________________________ ______ Clubbing ______________________________________

S.O.A.P Note Essay on Melanoma Assignment