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Focused Soap Note Of Skin Lesion Assignment

Focused Soap Note Of Skin Lesion Assignment

Patient information

Patient initials: RK

Age: 37 years old

Gender: female

Race: Caucasian

Subjective

CC: “skin lesions”

HPI: RK, a 37 year old Caucasian female presented to the clinic with a chief complain of skin lesion all over her body including her palms and feet. RK claims that there a time when she had painless chancre on her vulva and around the nipple but they disappeared after sometime. She reported that she had headache for two weeks which she tried managing using acetaminophen 500mg with minimal success. She denies dizziness, nausea and vomiting Focused Soap Note Of Skin Lesion Assignment.

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PMH: The patient is taking some over the counter paracetamol tablets to control her fever.

Family Hx: Non-contributory

Allergies: the patient has no known food or drug allergy

Social Hx: drinks occasionally. Not married but sexually active Focused Soap Note Of Skin Lesion Assignment.

ROS

HEENT: (+) mild headaches   (-) blurred vision (-) nervousness (-) confusion (-) ringing ears (-) nosebleeds (-) gums problems (-) xanthelasma.

Skin: (+) skin lesions (-) facial flushing (+) rash

Cardiovascular: (-) palpitations (-) chest pain (-) arterial symptoms (-) dyspnea (-) cyanosis, pigmentation, pallor tropic changes, and ulcer.

Respiratory: (-) wheezing (-) cough

Gastrointestinal:(-) vomiting (-)diarrhea (-) vomiting(-) epigastric pain(-) heartburn(-)

Endocrine :(-) weight loss  (-) heat / cold intolerance (-) excessive thirst

Genitourinary: (-) oliguria (+) dysmenorrhea (-) frank pain (-) dyspareunia (-) polyuria

Musculoskeletal :(-) arthralgia (-) back pain (-) weakness or strength

Ob-Gyn History : (-) pregnancy (+) sex life

Objective

PE:

  1. General appearance: conscious, mildly dull.
  2. Nutritional assessment: Weight –212 lbs, height –70 inches
  3. VS: BP 127/83; HR 68; RR16; Temp. 96.5F;
  4. Skin examination (+) skin lesions
  5. Planar and palmer exam: (+) lesions on the planar and palmer surface.
  6. Abdominal examination: (+) inguinal lymphadenopathy
  7. CVS examination: s1, s2 sounds present.

Assessment (Diagnosis)

Secondary syphilis

Plan:

Dx Plan:

  1. Differential diagnosis

Chancroid

Psoriasis

Lichen planus

  1. Lab tests

Dark field microscopy for observation of the bacteria -corkscrew morphology

Serologic tests

  1. Non-treponemal tests -to quantify concentration of cardiolipin in patient’s serum.
  2. Treponemal test –positive -detects the syphilis antigen.

Therefore the primary diagnosis is syphilis. Unique clinical features are painless chancre that disappears after sometime and involvement of palms and plantar surface of the feet. In addition, detection of syphilis antigen in serum confirms the diagnosis Focused Soap Note Of Skin Lesion Assignment.

Tx Plan:

Goals.

  1. Eradicate the bacteria causing infection.
  2. Manage pain -headache and fever.

Plan

  1. IM 2.4 million units Penicillin G stat.
  2. Continue with paracetamol tablets as prescribed until fever resolves.

Patient Education:

I would advise the patient to always use condoms whenever having sexual intercourse. Consistent and correct use of condoms is highly effective in preventing the spread of sexually transmitted diseases and HIV/AIDS (Ganley et al., 2021). Again is an effective method of contraception. In addition, it is advisable that even though she is not married, sticking to one sexual patner reduces the risk of contraction of sexually transmitted infections (Batamba, 2022). In this case, it is also necessary to treat the partner (s) to avoid re-infection Focused Soap Note Of Skin Lesion Assignment.

References

Batamba, I. (2022). Determinants of self-reported sexually transmitted infections among women in union in Busoga Region (Doctoral dissertation, Makerere University).

Ganley, K. Y., Wilson-Barthes, M., Zullo, A. R., Sosa-Rubí, S. G., Conde-Glez, C. J., García-Cisneros, S., … & Galárraga, O. (2021). Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City. Infectious diseases of poverty, 10(01), 36-45.

Case Study Discussion: Common Gynecologic Conditions, Part 2
Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as to the development of treatment plans.

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For this Case Study Discussion, you will develop a case study that demonstrates a gynecological disease process from your practicum experience or your professional practice that would be quite challenging for you as a clinician. You will then explore this case study to determine the diagnosis, diagnostic tests, and treatment options for the patient.
To prepare: Focused Soap Note Of Skin Lesion Assignment
• Consider a case study related to a patient that demonstrates a gynecological disease process in your practicum experience or professional practice that would be your biggest challenge as a clinician. Note: Possibly use your “FNP or AGPCNP Skills and Procedures Self-Assessment” in your practicum experience to guide your case study selection.
• Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.
• Use the Focused SOAP Note Template found in the Learning Resources to support your discussion. Complete a Focused SOAP note and critically analyze this and focus your attention on the diagnostic tests.
By Day 3
Based on your case study, post the following:
• POST A Focused SOAP NOTE only and describe your case study.
• Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning. Focused Soap Note Of Skin Lesion Assignment
• Also, share with your colleagues your experiences as well as what you learned from these experiences.
Use your Learning Resources and/or evidence from the literature to support your thinking and perspectives.
Read a selection of your colleagues’ responses.

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By Day 6
Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options that your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! Focused Soap Note Of Skin Lesion Assignment