Nursing
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.
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.
ANSWER
SOAP Assessment
Patient Initials: __JR_____ Age: __45_____ Gender: ____F___
SUBJECTIVE DATA:
Chief Complaint (CC): Painful, rash and red bumps on the upper trunk and arm.
History of Present Illness (HPI): JR is a 45-year-old Caucasian woman present in the clinic with an onset of a painful plaque-like rash and red bumps on her upper trunk and arm. She states that it began two weeks ago as a small bump on her arm that developed into an extended painful rash spreading on her upper arm and trunk. She claims the rash and red bumps are sore, itchy, and painful. JR reports that she changed her laundry detergents and washing soap, yet the rash and red bumps spread and increased. JR also began taking ibuprofen 400mg thrice, which minimized the pain. On a scale of 10, JR reports the pain at 7/10.
Medications:
- Ibuprofen 400mg PO, thrice in a day (Over the counter medication)
- Daily multivitamins
Allergies:
No known drug and food allergies
Past Medical History (PMH):
- Thyroid nodules
- Hypothyroid
- Hypertension, well-controlled
Past Surgical History (PSH):
- Appendectomy 2000
- Tonsillectomy 1997
Sexual/Reproductive History:
- Heterosexual
- G2P2AO
- Non- menstruating- TAH 2008
Personal/Social History:
JR is a widow whose husband died five years ago. She lives in an apartment with her two children, ages 15 and 13. She admits to taking a few glasses of wine, such as two glasses, bi-weekly. She denies smoking as well as substance use, namely the illicit drugs. She seldom exercises; however, when time allows, she does home fitness or attends a nearby gym when her children are at school. JR maintains a healthy diet both for her and her children.
Immunization History:
Her immunization, as per the CDC immunization and vaccination schedule, is up to date. The last Tdap was administered in 2010, and her annual flu vaccine is maintained even for this year. However, JR does not meet the criteria of the pneumonia vaccination.
Significant Family History:
JR is 45 years old, a mother of two, a boy (16 years) and a girl (13 years). She was widowed in 2015, five years ago. Her husband died in the line of duty when he tried to rescue a student from a school fire. Her parents, both mother, and father are alive. Her father is 70 years with a history of eczema, currently treating and managing Alzheimer’s disease, and has multiple food allergies. Her mother is 68 years, with Type 2 diabetes. The parents live within the neighborhood, making it easy for JR and the children to visit and watch over them. Maternal grandmother and paternal grandfather died in recent years. JR has three siblings, two brothers (38 and 35 years), and a sister 47 years old. The two brothers do not have a recent medical issue; however, the sister has diabetes, recently diagnosed in 2018.
Lifestyle:
JR works in the neighborhood supermarket/mall as a store manager during the day, where she has worked for the last ten years and volunteers for three-night shifts in a restaurant. She lives in a mortgaged apartment that she tries to pay all bills with her day and night jobs. The two jobs provide an opportunity to acquire complementary capital that she can use to pay all bills. Her apartment is within the work area, and the school for her children is a twenty-minute drive. She owns a car that she and her husband had bought. She uses it to take her children to school, to save the money bus, ultimately paying off her bills. When working at night, she leaves the children with her parents or with her neighbor friend, whose children are close friends of her children. JR ensures that her children and herself maintain a healthy feeding and nutritional regimen. However, maintaining this health habit currently remains strained, as she has to work double shifts that leave her exhausted and burned out. In addition, her exercise plan is also strained due to much work as a mother and career woman.
REVIEW OF SYSTEMS
General: Overly JR is a healthy 45-year-old Caucasian woman, neatly groomed, joyous, and polite. She appears in the clinic with an onset of a painful plaque-like rash and red bumps on her upper trunk and arm. Two weeks ago, it began as a small bump on her arm that developed into an extended painful rash spreading all over her upper arm and trunk.
HEENT: JR denies any changes in vision or hearing. However, she wears corrective glasses when reading or driving and has annual checkups with an ophthalmologist. Her last checkup was last year, June 10.
Neck: Denies any pains, stiffness, injuries, or lumps on the neck
Breasts: Opposes neither feeling any pain and tenderness on her breasts nor seeing any discharge. No Performs self-breast examination monthly and undergoes annual clinical breast exams at her gynecologist. No history of rashes or abnormal mammograms
Respiratory: Denies having any chest pains, discomforts, or experiencing irregular heartbeats. CV: Has a regular pulse
GI: Opposes the presence of nausea or vomiting. No reports on changing bowel habits
GU: No report on urinary symptoms
MS: No history of trauma
Psych: Presence of sleep disturbance due to constant working and burning out from the two shifts. Increased stress due to her work schedule and difficulties balancing work and life. Lacks a history of mental health and denies any suicidal thoughts
Neuro: Denies having any changes in her cognitive or thinking patterns. Denies any presence of falls, seizures, and mobility coordination problems
Integument/Heme/Lymph: Denies any history of skin cancer and any bleeding disorder
Endocrine: Lacks a history of hormone therapy
Allergic/Immunologic: Denies the presence of any immune deficiencies or immunologic disorder. No known history of food or drug allergies
OBJECTIVE DATA
Physical Exam
Vital signs: T-96.8 Oral; P-82, regular; BP-112/67 right arm, sitting, regular adult cuff, RR-18, non-labored; Ht: 5’6. Wt: 130lbs, BMI 21
General: AAOx3. Well-groomed. Not distressed. Appears uncomfortable
HEENT: PERRLA, EOMI, oronasopharnyx clear. No redness or swelling
Chest/Lungs: Clear and equal breath sounds. AP&L
Heart/Peripheral Vascular: Regular rhythm. No murmur, rub or gallop. Pulses +2 bilateral radials and +2 bilateral pedals
ABD: No organomegaly. Nabs x4 quadrants
Skin/Lymph Nodes: No edema, cyanosis, clubbing, or palpable nodules. Ruby red papular rash on the upper trunk, sore, painful, and itchy.
ASSESSMENT:
Lab Tests and Results: CBC-WBC 8,000
Diagnostic: Skin biopsy- fungal infection (Negative), shingles dx (Positive)
Priority Diagnosis: Shingles
Differential Diagnosis
- Cellulitis
- Chickenpox
- Insect bites
The patient’s symptoms, rash description, and assessment show that the patient suffers from shingles (Heineman, Cunningham, & Levin, 2019). This is because shingles symptoms, according to Wantabe (2019), presents rashes with excoriating pain, which is what the patient described: burning, itchy, and painful feeling (Watanabe, 2019). According to Patel and Nair (2020), shingles occur due to immune defense failure to control the causal virus’s latent replication. Moreover, primary triggers include emotional stress (Nair & Patel, 2020). According to the patient’s clinical presentation and history, emotional stress is prominent and present in her life; however, she lacks any immune disorder. Cellulitis is the skin’s bacterial infection, which is perceived deeply in the tissues and beneath the skin. Using the clinical results and patient history, there lacks any fungal or bacterial infection. Moreover, the examination shows a lack of swollen lymph nodes, eliminating the presence of cellulitis (Myhre & Sifris, 2020). Chickenpox is another contender whereby the rash should be scattered and spread all over the body. In this case, the rash is in a particular area.
References
Heineman, T., Cunningham, A., & Levin, M. (2019). Understanding the immunology of Shingrix, a recombinant glycoprotein E adjuvanted herpes zoster vaccine. Curr. Opin. Immunol, 59:42-48.
Myhre, J., & Sifris, D. (2020, August 23). Symptoms of Shingles. Retrieved from https://www.verywellhealth.com/shingles-signs-and-symptoms-48650#:~:text=Cellulitis%20is%20another%20skin%20infection,the%20American%20Academy%20of%20Dermatology.
Nair, P. A., & Patel, B. C. (2020). Herpes Zoster (Shingles). StatPearls Publishing LLC. https://www.ncbi.nlm.nih.gov/books/NBK441824/.
Watanabe, D. (2019). Cutaneous Herpesvirus Infection. Brain Nerve, Vol 71(4):302-308.
