Comprehensive SOAP Template (MELANOMA)
NOTE: ONLY COMPLETE THE SOAP TEMPLATE BELLOW
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 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
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.

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