Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

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 This week you will be submitting your paper in SOAP format.  The template and the grading rubric for this format is located in the Course Info folder.  This is the format approved for this course, so please follow it.  You will be choosing one skin graphic to write your SOAP note. Need to organize your data in this format…..and under “S” you will need to ask your questions…but obviously your patient cannot answer you.  So….under “S”….list all of the questions that you would ask the patient from the template list, including Meds, Allergies, ROS, etc…….think about everything that you would need to know and ask to make a clinical decision.  The “O” is what the condition looks like.  This is the objective piece of the note…..you do not ask the patient questions here, it is just what you observe.    Be specific!!!  Describe the lesion ie:  size, location, characteristics, etc….  think of this as documenting directly in a patient’s chart.  A/P are your list of differentials with rationale on why you chose those diagnosis.  You list them from most likely to least likely.

· This week you will be submitting your paper in SOAP format.  The template and the grading rubric for this format is located in the Course Info folder.  This is the format approved for this course, so please follow it.  You will be choosing one skin graphic to write your SOAP note. Need to organize your data in this format…..and under “S” you will need to ask your questions…but obviously your patient cannot answer you.  So….under “S”….list all of the questions that you would ask the patient from the template list, including Meds, Allergies, ROS, etc…….think about everything that you would need to know and ask to make a clinical decision.  The “O” is what the condition looks like.  This is the objective piece of the note…..you do not ask the patient questions here, it is just what you observe.    Be specific!!!  Describe the lesion ie:  size, location, characteristics, etc….  think of this as documenting directly in a patient’s chart.  A/P are your list of differentials with rationale on why you chose those diagnosis.  You list them from most likely to least likely.

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 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.]

Comprehensive SOAP Template

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: Include last 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, include what 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?

Week 4 SOAP Example

· 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 3 different references from current evidence based literature.

Comprehensive SOAP

Patient Initials: __JJ_____ Age: __54_____ Gender: __M_____

SUBJECTIVE DATA:

Chief Complaint (CC): Small, itchy, raised patches on lower back

History of Present Illness (HPI): Jeremiah Jergens is a 54-year-old Caucasian male who presents today with a large cluster of thick, red, raised patches on his lower back. Jeremiah first noticed the patches 4 years ago, a few days after he recovered from a strep throat infection. He has associated symptoms of tenderness, itchiness and flaking of the patches. They often bleed when he accidently scratches off a patch. He reported the he is “embarrassed by the look of it” and will not take his shirt off at the beach. He has also noticed both his knees, joints in his fingers and back are very stiff in the mornings but lessens after walking and using his joints for a bit. He has been using Tylenol to help with the joint pain and for the patches, he reports using Benadryl ointment for the itching. Both provide minimal relief. He rates his discomfort a 4/10 today but in mornings 7/10 due to the joint pain.

Medications:

1. Over-the-counter Tylenol 500mg PO once daily in the morning

2. Over-the-counter Benadryl Extra Strength topical ointment as needed

3. Atenolol 75 mg PO twice daily

4. Over-the-counter Aspirin 325 mg PO once daily

5. Men’s Multivitamin once daily

6. Epi-Pen as needed

Allergies:

1. Penicillin – rash

2. Salmon – anaphylaxis

3. Peaches – lip itching

Past Medical History (PMH):

1. Chicken Pox – age 5

2. Streptococcal Pharyngitis, recurrent– age 50

3. Morbid obesity

Past Surgical History (PSH):

1. Gastric bypass surgery – age 52

2. Appendectomy – age 23

3. Tonsillectomy – pt states “I was about 7 years old”

4. Vasectomy – age 32

Sexual/Reproductive History:

Heterosexual

Vasectomy – age 32

Personal/Social History:

He quit smoking 8 months ago after smoking 2.5 packs daily x 31 years; has an occasional beer during social outings; denies any drug use; enjoys hiking, riding his motorcycle, spending time at the beach with his 5 grandchildren; exercise 5 days a week; eating habits have been “much better since the weight loss surgery”. Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

Immunization History:

Agrees to receive his influenza and Pneumococcal today. All other immunizations are up to date.

Significant Family History:

Diabetes – mother dx late 30s

Hypertension – maternal grandparents, mother, brother all dx in late 30s

Arthritis – paternal grandfather, father both dx early 40s

Psoriasis – father dx date unknown

2 healthy daughters and 2 grandchildren

Lifestyle:

He is married to his wife of 32 years. Together they travel the country in their RV and motorcycles. He has owned his home for the past 28 years in the suburbs. At 25 years as a U.S. Marine, he retired and receives full benefits of $75,000 annually. He and his wife both receive social security benefits. No financial issues. First born daughter rents the basement with her 2 children ages 5 and 12.

Following his gastric bypass surgery, his health taken a turn for the better by decreasing his meat and increasing his vegetable intake. His total weight loss since the surgery is 143 lbs. He is now only taking one blood pressure medication, down from two. 5 days a week, he exercises at the local YMCA. When he is not traveling the country, he attends church Mondays and Thursdays for Bible study. He also leads the marriage ministry for newlyweds. He has a great support system including his friends and family.

Review of Systems:

General: Negative for recent sudden weight changes, weakness, fatigue, anorexia, malaise, or fever

HEENT: negative for headache, head injury, visual changes, blurring of vision, itching, last eye exam 2/15/18. Negative for diplopia, floaters, loss of any visual fields, history of cataracts or glaucoma, pain, redness, excessive tearing. Negative for tinnitus, recent ear infections, hearing loss, change in hearing. Negative for epistaxis, frequent colds, nasal congestion, discharge, pain, post-nasal drip, change in ability to smell, history of nasal polyps, hay fever, and sinus trouble. Negative for mouth soreness, dryness, bleeding gums, throat soreness, pyorrhea, ulcers, and teeth dentures. Positive for recurrent strep throat infections (3 within 5 months) and dental caries.

Neck: negative for painful lymphnodes, enlarged lymphnodes, goiter

Breasts: negative for new or changing breast lumps, nipple changes or nipple discharge, gynecomastia

Respiratory: negative for cough, hemoptysis, wheezing, shortness of breath, dyspnea, pleuritic chest pain, cyanosis, recurrent pneumonia, environmental exposure, history of exposure to TB, last TB skin test 4/3/17-negative

Cardiovascular/Peripheral Vascular: negative for chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, edema, palpitations, murmur, varicosities, history of rheumatic fever, syncope, claudication, thrombophlebitis. Positive for hypertension and history of abnormal electrocardiogram

Gastrointestinal: negative for abdominal pain, nausea, vomiting, hematemesis, constipation, diarrhea, hemorrhoids, dysphagia, odynophagia, food intolerance, early satiety, indigestion, heartburn, change in appetite, change in bowel pattern, rectal bleeding, melena, excessive flatulence or belching, liver or gallbladder problems, jaundice, history of hepatitis

Genitourinary: negative for dysuria, penile discharge, lesions, incontinence, changes in voiding, hematuria, frequency, suprapubic pain, nocturia, trouble initiating urinary stream, incomplete emptying, polyuria, stones, history of urinary tract infections, history of sexually transmitted infections, testicular pain, or swelling, scrotal mass, sexual difficulties, impotence, hernias. Positive for vasectomy at age 32

Musculoskeletal: negative for new gait disturbance, new weakness, recent fall, gout, arthritis. Positive for lower back pain, pain in joints of fingers, bilateral knee pain and stiffness with limited range of motion especially in the mornings

Psychiatric: negative for depression, anxiety, hallucinations, suicidal ideation, homicidal ideation, nightmares, nervousness, irritability, hypersomnia, insomnia, phobias. Positive for low self-esteem due to finger nail changes and patches on back

Neurological: negative for headaches, numbness/tingling, visual changes, seizures, falls, blackouts, local weakness, tremors, memory changes, muscle atrophy, vertigo or dizziness

Skin: negative for skin lesion changes, petechiae, bruising, sores, changed in moles, changes in hair.

Hematologic: negative for hematemesis, hematochezia, hemoptysis, prolonged bleeding, other bleeding problems, blood transfusion

Endocrine: negative for polyphagia, polyuria, polydipsia, heat intolerance, cold intolerance, sudden weight gain, sudden weight loss, history of diabetes or thyroid issues

Allergic/Immunologic: negative for seasonal allergies, recurrent serious infections. Positive for food allergy to salmon and peaches. Positive for drug allergy for Penicillin. Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 119/72 (right arm, large cuff, sitting) | Pulse 78 | Temp 98 °F (36.7 °C) (Oral) | Resp 18 (non-labored) | Ht 6′ 3.75″ (1.924 m) | Wt 196 lb (85 kg) | BMI 24 kg/m²

General: Alert and orientated to time, place, and person, well appearing, and in no distress. Appears comfortable during history taking

HEENT: Skull normocephalic, atraumatic, sparse hair with balding. PERRLA, light reflex present, oronasopharynx is clear

Neck: supple, no palpable thyroid, midline trachea, no enlarged neck nodes, bruit, jugular vein distension, tmegally

Chest/Lungs: clear to auscultation, no wheezes, rales or rhonchi, rubs, symmetric air entry, resonance on percussion, fremitus on palpation

Heart: normal rate, regular rhythm, normal S1, S2, no murmurs, thrills, rubs, clicks or gallops

Peripheral Vascular: peripheral pulses normal, no pedal edema, no clubbing or cyanosis

Abdomen: Abdomen soft, nontender, nondistended, no scars, masses hernia, aortic pulsations, or organomegaly, bowel sounds present

Genital/Rectal: No penile lesions or discharge, testicular lump, no hernias, uncircumcised. Rectal exam: negative without mass, lesions or tenderness.

Musculoskeletal: Bilateral knee exam –positive for crepitation on left knee, no swelling good ROM right knee -no swelling, no crepitation good ROM. Muscle strength symmetric 5/5 all groups. Positive for mild swelling in joint of all fingers

Neurological: reveals alert, oriented, normal speech, no focal findings or movement disorder noted. Gait regular, no involuntary movements. Cranial nerves II-XII grossly intact, DTR’s intact

Skin: normal coloration and turgor, has benign small moles on chest, has cluster of well-demarcated red plaques >20% BSA macules and coarse scales on lower back, elbows, and along hairline (Gladman, Shuckett, Russell, Thorne, & Schachter, 1987). Onycholysis, thickening, and pitting of fingernails (Mcgonagle, 2009). Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

ASSESSMENT:

Lab Test and Results:

1. Skin biopsy and Periodic acid–Schiff–diastase (PAS-D) stain – positive for epidermal hyperplasia

2. RH factor – negative

3. HLA-B27 – positive

4. Nail culture using Potassium hydroxide (KOH) preparation – negative for nail fungus

5. Auspitz sign – positive (Bernhard, 1990)

6. Radiology — “pencil-in-cup” phenomenon in both index fingers and right ring finger (Siannis, Farewell, Cook, Schentag, & Gladman, 2006).

7. Serum Urate – 5.2 mg/dL

Priority Diagnostics:

A. Chronic Plaque Psoriasis

B. Nail Psoriasis

C. Psoriasis Arthritis

Differential Diagnosis (DDx):

a. Nummular eczema

b. Seborrheic Dermatitis

c. Atopic Dermatitis

d. Superficial fungal infection

e. Onychomycosis

f. Lichen Planus

g. Rheumatoid Arthritis

h. Reactive Arthritis

i. Gout

Diagnoses/Client Problems:

1. HTN, controlled

2. Allergy to Penicillin (rash), salmon (anaphylaxis), peaches (lip itching), controlled

References

Bernhard, J. D. (1990). Auspitz sign is not sensitive or specific for psoriasis. Journal of the American Academy of Dermatology, 22(6), 1079-1081. doi:10.1016/0190- 9622(90)70155-b Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

Gladman, D. D., Shuckett, R., Russell, M. L., Thorne, J. C., & Schachter, R. K. (1987). Psoriatic arthritis (PSA) – An analysis of 220 patients. QJM: An International Journal of Medicine, 62(238-241), 127. doi:10.1093/oxfordjournals.qjmed.a068085

Mcgonagle, D. (2009). Enthesitis: An autoinflammatory lesion linking nail and joint involvement in psoriatic disease. Journal of the European Academy of Dermatology and Venereology, 23(S1), 9-13. doi:10.1111/j.1468- 3083.2009.03363.x

Siannis, F., Farewell, V. T., Cook, R. J., Schentag, C. T., & Gladman, D. D. (2006). Clinical and radiological damage in psoriatic arthritis. Annals of the Rheumatic Diseases, 65(4), 478-81. doi:10.1136/ard.2005.039826 Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

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For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. Differential Diagnosis for Skin Conditions (NURS 6512: Advanced Health Assessment)

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