Assignment 1: Lab Assignment: Differential Diagnosis For Skin Conditions
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.
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.
book link
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
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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 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.
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):
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):
1.) Cholecystectomy 1994
2.) 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.
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
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 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.]
© 2019 Walden University Page 4 of 4
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Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
· Chapter 9, “Skin, Hair, and Nails” This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
This section explains the procedural knowledge needed prior to performing various dermatological procedures.
Chapter 1, “Punch Biopsy”
Chapter 2, “Skin Biopsy”
Chapter 10, “Nail Removal”
Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
Chapter 24, “Suture Removal”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 28, “Rashes and Skin Lesions” This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
· Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)
VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals
This interactive website allows you to explore skin conditions according to age, gender, and area of the body.
Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&AN=103968541&site=ehost-live&scope=site
Note: You will access this article from the Walden Library databases.
Document: Skin Conditions (Word document)
This document contains five images of different skin conditions. You will use this information in this week’s Discussion.
Document: Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template (Word document)
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_4_Assignment_1_Rubric
| Excellent | Good | Fair | Poor | |
| Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic. | Points:Points Range: 30 (30%) – 35 (35%)The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.Feedback: | Points:Points Range: 24 (24%) – 29 (29%)The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.Feedback: | Points:Points Range: 18 (18%) – 23 (23%)The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.Feedback: | Points:Points Range: 0 (0%) – 17 (17%)The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.Feedback: |
| · Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature. | Points:Points Range: 45 (45%) – 50 (50%)The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.Feedback: | Points:Points Range: 39 (39%) – 44 (44%)The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.Feedback: | Points:Points Range: 33 (33%) – 38 (38%)The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.Feedback: | Points:Points Range: 0 (0%) – 32 (32%)The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.Feedback: |
| Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. | Points:Points Range: 5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.Feedback: | Points:Points Range: 4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.Feedback: | Points:Points Range: 3 (3%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.Feedback: | Points:Points Range: 0 (0%) – 2 (2%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.Feedback: |
| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation | Points:Points Range: 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.Feedback: | Points:Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.Feedback: | Points:Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.Feedback: | Points:Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.Feedback: |
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. | Points:Points Range: 5 (5%) – 5 (5%)Uses correct APA format with no errors.Feedback: | Points:Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.Feedback: | Points:Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.Feedback: | Points:Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors.Feedback: |
Show Descriptions Show Feedback
Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic.–
Levels of Achievement:
Excellent 30 (30%) – 35 (35%)
The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.
Good 24 (24%) – 29 (29%)
The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.
Fair 18 (18%) – 23 (23%)
The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.
Poor 0 (0%) – 17 (17%)
The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.
Feedback:
· Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.–
Levels of Achievement:
Excellent 45 (45%) – 50 (50%)
The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
Good 39 (39%) – 44 (44%)
The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.
Fair 33 (33%) – 38 (38%)
The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.
Poor 0 (0%) – 32 (32%)
The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.
Feedback:
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Levels of Achievement:
Excellent 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Good 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Fair 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
Poor 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Feedback:
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation–
Levels of Achievement:
Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Feedback:
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.–
Levels of Achievement:
Excellent 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Feedback:
| Total Points: 100 |
Name: NURS_6512_Week_4_Assignment_1_Rubric
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Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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�Note to Build: These images are still pending permissions so I don’t have credit lines yet or approval.
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Key Points
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th EditionChapter 08 : Skin, Hair, and NailsKey PointsThis review discusses examination of the skin, hair, and nails.Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass or dermatoscope; and Wood’s lamp.To examine the skin, perform the following.Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.Inspect the skin in two ways.First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences among body areas, and compare sun-exposed areas with areas that were not exposed to the sun.Second, observe the skin as each part of the body is examined.When evaluating the skin and mucous membranes in each part of the body, note six characteristics.The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is at areas of pressure or rubbing, such as the elbows, soles, and palms.The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.The fifth characteristic is hygiene, which may contribute to skin condition.The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.During inspection, also palpate the skin to determine five characteristics.First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm but should be bilaterally symmetrical.Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined.First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.If the lesion has exudates, note their color, odor, amount, and consistency.If there is more than one lesion, describe their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.Record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.Use a light and magnifying glass to determine the lesion’s subtle details, including color, elevation, and borders.To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection.To examine the hair, perform the following.To assess the hair, palpate its texture. Scalp hair may be coarse or fine and curly or straight. It should be shiny, smooth, and resilient.During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.Hair color ranges from very light blond to black to gray.Hair distribution and quantity vary with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.To examine the nails, perform the following.Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.Inspect the nails for six characteristics: color, length, condition, configuration, symmetry, and cleanliness.Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.The nails should appear bilaterally symmetrical.The nails should be clean, smooth, and neat.Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.The nail-base angle should measure 160 degrees.If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.The texture of the nail plate should be hard and smooth.The nail base should be firm—not boggy.The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad.
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Student Checklist
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th EditionChapter 0 8: Skin, Hair, and NailsStudent ChecklistAssessed Appropriately by Student?YesNoCommentsI. Inspection and palpation of the skinA. ColorB. UniformityC. ThicknessD. SymmetryE. HygieneF. Lesions1. Primary2. Secondary3. Size4. Shape5. Color6. Texture7. Elevation or depression8. Attachment at base9. Exudates10. Configuration11. Location and distributionG. OdorsH. MoistureI. TemperatureJ. TextureK. TurgorL. MobilityII. Inspection and palpation of the hairA. ColorB. DistributionC. QuantityD. TextureIII. Inspection and palpation of the nailsA. Pigmentation, length, symmetry, and ridging or irregularities (redness, swelling, pain, exudate, warts, cysts, or tumors)B. Measure nail base angleC. Texture, firmness, thickness, uniformity, and adherence to nail bed
