Comprehensive SOAP Template (MELANOMA)

NOTE: ONLY COMPLETE THE SOAP TEMPLATE BELLOW

http://coursewareobjects.elsevier.com/objects/elr/Seidel7e/IC/jpg/Chapter08/008008.jpg

John Smith is 62 y/o male, retired, PMH: Diabetes M,HTN, he living in New York city ,he reported since a few weeks has a sore and a mole dark in color and an area of the skin that rapidly changed the borders and shape, a dark blue skin lesson which is hard and black located on his left arm, he feels uncomfortable, with pain upon palpation .Today John Smith has called his primary doctor for an appointment .

Medication: Metformin 500 mg, BID. Aspirin 81 mg daily, Lisinopril 20 mg daily

Allergy: Penicillin, Iodine

Present medical history: Diabetes M, HTN

Family medical history: Mother: Melanoma Cancer

Father: HTN, Cholesterol, Diabetes M

NOTE:

Use Clinical Terminologies to Explain the Physical Characteristics featured in the graphic.

4-Formulate a Differential Diagnosis of FIVE possible conditions for the skin graphic that you chose.

5-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.

Patient Initials: Age: Gender:

-SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergy

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History: If applicable

Personal/Social History:

Immunization History:

Significant Family History:

Lifestyle

General

Skin:

Physical Exam:

Vital signs:

Review of Systems:

HEENT:

Breasts:

Respiratory:

CV

GI

GU:

MS

Psych:

Neuro

Integument/Heme/Lymph:

Endocrine:

Allergic/Immunologic

-OBJECTIVE DATA

Physical Exam:

Vital signs:

General: A&O x3, NAD,

HEENT: PERRLA, EOMI,

Neck

Chest/Lungs: CTA AP&L

ABD

Genital/Rectal:

Musculoskeletal: symmetric muscle development -

Neuro:

Skin/Lymph Nodes:

-ASSESSMENT:

Lab Tests and Results:

Diagnostics:

Lab:

Radiology:

CXR –

EGC

Differential Diagnosis (DDx):

Diagnoses/Client Problems:

-PLAN:

REFERENCES:

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.

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