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Evaluation And Management of Dermatological Conditions Essay

Evaluation And Management of Dermatological Conditions Essay

Episodic/Focused SOAP Note

Patient Initials: Y.Y.

Age: 17 years

Gender: Male

Race: Caucasian

SUBJECTIVE DATA:

Chief Complaint (CC): Itchiness.

History of Present Illness (HPI): The patient is a 17-year-old Caucasian male who presents to the clinic complaining of itchiness on his hands. The itchiness began two days ago after he helped his uncle clean and organized his garage. The itchiness is accompanied by pain that worsens daily, and his hands appear scalded. He rates the pain on a scale of 5 out of ten. he used a cream bought by his mother which gave him temporary relief. He doesn’t recall the name of the cream.

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Current Medications: Paracetamol 1000mg TDS PRN

Allergies: No known drug allergy. No known food allergies.

Past Medical History (PMH): He suffers from migraines which he manages using paracetamol tablets. His immunization is up to date. He was last admitted to the hospital last year for pneumonia. Evaluation And Management of Dermatological Conditions Essay

Social History: The patient is a junior high student at the neighboring school. He lives with his mother when schools are open and his father during the holidays. He maintains a healthy lifestyle by playing football at school and exercising at the neighborhood gym with his friends. He is under his mother’s comprehensive medical cover. He has been exposed to alcohol, cigarettes, and other abused substances. He has taken alcohol once and reports that he did not like it.

Family History: The patient is an only child. His mother is alive and healthy, while his father is a known diabetic. His paternal grandparents both died of diabetes complications. His maternal grandmother is alive with dementia, and his maternal grandfather dies of prostate cancer.

Surgical History: No surgical history.

Mental History: There are no concerns about mental and psychological health.

Violence History: There are no concerns about violence.

Reproductive History: Sexually inactive.

Review of Systems:

General: Denies headache, fever, chills, night sweats, day sweats, fatigue, daytime sleepiness, sleep disturbances, weight gain, or weight loss.

HEENT/Neck: Denies difficulty swallowing, sore throat, and rhinorrhea. Denies double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Denies changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. Denies dry mouth, oral lesions, gum bleeding, or nasal congestion.

Skin: Reports itching, scarring, and pain in his hands. Denies skin growth and lesions. Evaluation And Management of Dermatological Conditions Essay

Cardiovascular/Peripheral Vascular: Denies lightheadedness when standing, paroxysmal nocturnal dyspnea, leg edema, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

Respiratory: Denies cough, wheezing, choking when swallowing, shortness of breath, holding breath during sleep, or sputum production.

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies painful urination, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine.

Neurological: Denies memory loss, changes in memory, loss of consciousness, headache, seizures, confusion, difficulty balancing, numbness, tingling sensation, changes in thinking patterns, spells of blindness, or dizziness.

Musculoskeletal: Denies muscle pain, back pain, stiffness, or joint pain.

Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.

Lymphatics: Denies swollen lymph nodes.

Psychiatric: Denies history of suicidal thoughts, depression, or bipolar disorder.

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Endocrinology: Denies weight gain, hair loss, hot flushes, weight loss, and frequent urination.

Reproductive: Sexually inactive.

Allergies:  reports itching, pain, and scarring on the hands. Denies rhinitis or history of asthma.

OBJECTIVE DATA:

Physical Exam:

Vital signs: B/P 133/62 mmHg, HR-73 bpm, SPO2- 97% on room air, Temp 98.3, RR-19 bpm, Height- 159cm, Weight- 50kgs, BMI 19.8. Evaluation And Management of Dermatological Conditions Essay

General: The patient is cooperative, hygienic, and well dressed. The patient appears uncomfortable.

HEENT: Clear oronasophaynx, PERRLA, normocephalic head, no visual acuity issues.

Neck: Neck has a full range of motion in all directions, normal symmetry, and normal length. On palpation, swollen, tender anterior lymph nodes.

Respiratory: On palpation, no tenderness or palpable mass. On auscultation, normal breath sounds without wheezing or audible breath sounds. No chest deformities.

Heart/Peripheral Vascular: On palpation, normal heart size and normal heart location. On auscultation, normal heart rate, normal rhythm, and no murmurs. Normal extremities.

Abdomen: Liver and spleen of normal size, normal tenderness, and normal consistency.

Genital/Rectal: This examination was not conducted.

Lymphatic: Swollen, tender anterior lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Psychiatric: Normal mood, memory, awareness of context, and orientation to time and place,

Skin: Normal complexion for his ethnicity. The skin on his arms is itching and appears scalded.

Diagnostic Results:

Complete blood count: This test is recommended to rule out thrombocytopenia and immunodeficiency.

Serum IgE level: This test is recommended to rule out atopic dermatitis (Godwin et al., 2021). The results showed a serum IgE level within the normal range.

Fungal culture: This is recommended to rule out tinea infections.

Patch testing: This is recommended to identify the irritant or allergen causing a reaction. This test is specifically used to exclude allergic contact dermatitis (Belluco et al., 2022)Evaluation And Management of Dermatological Conditions Essay.

ASSESSMENT:

Differential Diagnosis (DDx):

Irritant contact dermatitis: This is a nonallergic response that occurs on the skin when exposed to corrosive agents such as soaps and chemicals (Litchman et al., 2022). Y.Y.’s symptoms began after he had cleaned the garage using detergents and rearranged everything in the garage, including chemicals.

Allergic contact dermatitis: This skin condition is characterized by relapsing or persistent dermatitis on exposure to an allergen (Murphy et al., 2021). The skin condition develops within a few days of exposure to the allergen. Y.Y. experienced his symptoms two days after cleaning and arranging the garage.

Atopic dermatitis:  This is an inflammatory skin condition that causes drying, itching, lichenification, and inflammation of the skin in the face, arms, legs, and cheeks (Kolb & Ferrer-Bruker, 2021)Evaluation And Management of Dermatological Conditions Essay.

PLAN

Additional tests: I would have included an HIV test apart from the conducted tests. Although Y.Y. is sexually inactive, HIV can be transmitted through other ways apart from sexual transmissions, such as sharing sharp objects with an infected person.

Therapeutic interventions: The primary diagnosis is irritant contact dermatitis. Treatment aims to identify and withdraw the causative agent (Litchman et al., 2022). Y.Y.’s symptoms began after he had cleaned and arranged the garage. He explains that he used detergent when cleaning, and the chemicals he arranged were sealed correctly. The causative agent, in this case, is the detergent. The patient is prescribed ceramide cream and topical hydrocortisone.

Referral: There was no need to refer the patient to a dermatology specialist since the patient was not in an emergency.

Follow-up: The follow-up is scheduled for one week to observe the patient’s progress.

Reflection: I learned that patch testing is still conducted to rule out the concern for allergic contact dermatitis in cases of irritant contact dermatitis (Belluco et al., 2022)Evaluation And Management of Dermatological Conditions Essay. I would have prescribed the ceramide cream only without including the topical hydrocortisone. Topical corticosteroids do not have a significant role in treating irritant contact dermatitis.

Health promotion and disease prevention: The patient is educated on the suspected irritant and advised to avoid further contact (Gabros et al., 2021). Y.Y. is advised to constantly clean and dry his hands before applying the prescribed topical medications. Y.Y. is recommended to use the corticosteroid only within the specified duration since it is an immunosuppressant.

References

Belluco, P., Giavina-Bianchi, P., Belluco, R., Novaes, M., & Reis, C. (2022). Prospective study of consecutive patch testing in patients with contact dermatitis using an adapted Latin American baseline series. European annals of allergy and clinical immunology, 10.23822/EurAnnACI.1764-1489.250. Advance online publication. https://doi.org/10.23822/EurAnnACI.1764-1489.250

Gabros S, Nessel TA, Zito PM. Topical Corticosteroids. [Updated 2021 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532940/

Godwin L, Sinawe H, Crane JS. Biochemistry, Immunoglobulin E. [Updated 2021 Sep 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: Evaluation And Management of Dermatological Conditions Essay https://www.ncbi.nlm.nih.gov/books/NBK541058/

Murphy PB, Atwater AR, Mueller M. Allergic Contact Dermatitis. [Updated 2021 Sep 20]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532866/

Kolb L, Ferrer-Bruker SJ. Atopic Dermatitis. [Updated 2021 Aug 13]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448071/

Litchman G, Nair PA, Atwater AR, et al. Contact Dermatitis. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459230/

Focused SOAP Checklist

 SUBJECTIVE:

  • Chief Complaint: Did I state briefly in the patient’s own words
  • History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up) Evaluation And Management of Dermatological Conditions Essay
  • Medications: did I list each medication and reason.
  • Allergies: Did I include specific reactions to medications, foods, and insects, environmental?
  • Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses
  • Past Surgical History (PSH): Did I list the dates, indications and types of operations?
  • OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.
  • Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc
  • Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable
  • Family History: Did I list for Parents, Grandparents, siblings, children?
  • Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

  • Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?
  • Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?
  • Did I include the systems in a list format?
  • Did I include cardiovascular and respiratory systems regardless of cc?
  • Did I delete the systems I did not review? Evaluation And Management of Dermatological Conditions Essay

 ASSESSMENT:

  • Did I put my priority diagnosis in bold for EACH CC?
  • Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?
  • Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)
  • Did I include a reference citation for each diagnosis under the assessment area?
  • Are my assessments concise and in a chart format?
  • Did I put my differential diagnosis in order by priority?
  • Did I provide a detailed rationale for each diagnosis?

Holistic care:

  • Did I cover existing diagnoses and whether any changes need to be made?
  • Did I include needed preventative care based on my patient’s age and risk factors? Evaluation And Management of Dermatological Conditions Essay

PLAN:

  • Did I include a treatment plan?
  • Did I address if labs, x-rays, etc. were needed?
  • Did I include a pharmacological plan and citation for EBP?
  • Did I include non-pharmacological strategies?
  • Did I discuss alternative therapies if applicable?
  • Did I state when the patient needs a follow-up?
  • Did I indication if any referrals or consultations were necessary or not necessary?
  • Did I write a rationale based on evidence?
  • Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?
  • Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source? Evaluation And Management of Dermatological Conditions Essay

 REFLECTION:

  • Did I state what I learned from this experience?
  • Did I state what I would you do differently or if I would do everything the same and the rationale?
  • Did I state if I either agreed or disagreed with my preceptor based on evidence (and cite references for EBP?
  • Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.
  • Did I state the community resources in my area?

APA

  • Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)
  • Did I use at least 3-4 course resources?
  • Do I have the paper in a neat format?
  • Did I list my references in APA format? Evaluation And Management of Dermatological Conditions Essay

Developed by Joyce Turner, NP.  Revision 2/22/17 by Nancy Hadley, DNP, APRN, FNP-BC

To prepare:

  • Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
  • Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
  • Select an adolescent patient that you examined during the last 3 weeks that suffered from any dermatological condition. With this patient in mind, address the following in a Focused Note.

Assignment

  • Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why? Evaluation And Management of Dermatological Conditions Essay
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Please see attached focus note template and checklist. Please read the instructions and information required for each part on the template and cover all the information required in each part of the Template. Provide reference to support Diagnostic tests and Differential diagnosis.

Feel free to use any chief complaint pertaining to HEENT (sore throat, runny nose,…)

Please follow this example when completing the Diagnostic, assessment, and plan section.

Diagnostic results:

Please list diagnostic results and diagnostics that need to be obtained and support by references

Assessment.

Primary Diagnosis: first and 2 or 3 differentials diagnosis (say why you chose and support by references)

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Plan (Please it is important to cover all the contents and use heading for each section as follow.

  • Additional tests
  • Therapeutic interventions: (pharmacologic and non-pharmacologic)
  • Education
  • Referral:
  • Disposition/Follow up:
  • Reflection: (Do you agree or disagree with preceptor treatment plan, What would you do differently in a similar patient evaluation. New things learned)

Thank you again for the revised paper last time, do it like the way you did it on the revised paper

Thank you

Evaluation And Management of Dermatological Conditions Essay