The Hamilton Depression Rating Scale

The Hamilton Depression Rating Scale is the most widely used provider administered depression assessment scale. This assessment scale for treatment is the oldest and efficient form of clinical treatment for depression (Rohan, Rough & Vacek 2017). The rating scale has been proven to be useful in rating the patient’s depression level before, during, and after treatment. The Hamilton Depression Rating Scale, also known as that Ham-D, has a 17- original item to measure the patient’s level of depression. A later 21-item version added four items to intend the subtype of the depression. This discussion will describe the Hamilton Depression Rating Scale’s psychometric properties and the best time to use the treatment. The Hamilton Rating Scale for Depression Essay

Psychiatrist Dr. Max Hamilton created The Hamilton Rating Scale for Depression in the 1950s (Sharp, 2015). It was initially designed for inpatient hospitals with melancholic and physical symptoms of depression. It is also used to determine the performance of psychiatric medication, especially the first group of antidepressants. Over 40 years, the assessment was used to evaluate the patient’s mental status and assist diagnosing patients experiencing moderate to severe depression for a week or more. The patient’s interview should take 15 to 20 minutes, containing 17-21 items, and scored on a point system from 0-4. The first 17 items on The Hamilton Depression Rating Scale measures the depression symptoms. The additional four items for the 21-point scale measures factors that may be related to depression, but not known as severe, such as obsession, compulsive, and paranoia symptoms. The scoring system is based on the 17-item scale, the suggested ranges consist of 0-7 normal, 8-16 mild depression, and 17-23 moderated depression and scores over 24 are suggested severe depression The Hamilton Rating Scale for Depression Essay.

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Hamilton’s depression scale is used to rate depression in patients that are taking antidepressants. This form of assessment helps determine the outcome of the medication. It also helps determine if the dose should be increased or changed to a new medication. Besides, The Hamilton Depression Rating Scale provides proof to healthcare providers that mental illnesses are treatable and not indefinite (Worbys, 2013). A study conducted to evaluate further discrimination between placebo and active drugs to prove a dose-response relationship in patients with severe depression has caused concern when treating a patient with mental illnesses (Bech, 2010).

An improvement in the Hamilton Depression Scale Score during an assessment trial does not indicate that antidepressant has improved the patient medical status. The form of assessment is not statistically proven. Many statistical versus clinical significance problems occur when analyzing placebo-controlled trials, including dose-response relationships (Bech, 2010). The insufficient statistical data makes it challenging to determine if the Hamilton Depression Scale is efficient in evaluating the patient’s response when prescribed an antidepressant.

Despite the lack of statistical data, The Hamilton Depression Rate Scale has proven to determine patients’ effects from depression (Bech, 2010). Psychotherapy is a great way to evaluate the patient’s mental status further. As a PMHNP, not to base the final assumption based on the patient’s score after completing the Hamilton Depression Rating Scale but instead, us the scale to further treat the patient’s mental status.

Reference

Bech, P. (2006). Rating scales in depression: limitations and pitfalls. Dialogues in clinical neuroscience, 8(2), 207–215.

Worboys, M. (2013). The Hamilton Rating Scale for Depression: The making of a “gold standard” and the unmaking of a chronic illness, 1960-1980. Chronic illness, 9(3), 202–219. https://doi.org/10.1177/1742395312467658

Sharp, R. (2015). The Hamilton Rating Scale for Depression, Occupational Medicine, Volume 65, Issue 4, June 2015, Page 340, https://doi.org/10.1093/occmed/kqv043 The Hamilton Rating Scale for Depression Essay

 

Rohan, K., Rough, J., Vacek, P.(2018).A Protocol for the Hamilton Rating Scale for Depression: Item Scoring Rules, Rater Training, and Outcome Accuracy with Data on its Application in a Clinical Trial .J affects order, 200(6),111-118.

Discussion: Assessment Tools
Assessment tools have two primary purposes: 1) to measure illness and diagnose clients, and 2) to measure a client’s response to treatment. Often, you will find that multiple assessment tools are designed to measure the same condition or response. Not all tools, however, are appropriate for use in all clinical situations. You must consider the strengths and weaknesses of each tool to select the appropriate assessment tool for your client. For this Discussion, as you examine the assessment tool assigned to you by the Course Instructor, consider its use in psychotherapy.

Learning Objectives
Students will:
Analyze psychometric properties of assessment tools
Evaluate appropriate use of assessment tools in psychotherapy
Compare assessment tools used in psychotherapy
Note: By Day 1 of this week, the Course Instructor will assign you to an assessment tool that is used in psychotherapy.

To prepare:

Review this week’s Learning Resources and reflect on the insights they provide.
Consider the assessment tool assigned to you by the Course Instructor.
Review the Library Course Guide in your Learning Resources for assistance in locating information on the assessment tool you were assigned. The Hamilton Rating Scale for Depression Essay
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click Submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before clicking Submit!

By Day 3
Post an explanation of the psychometric properties of the assessment tool you were assigned. Explain when it is appropriate to use this assessment tool with clients, including whether the tool can be used to evaluate the efficacy of psychopharmacologic medications. Support your approach with evidence-based literature The Hamilton Rating Scale for Depression Essay.

Read a selection of your colleagues’ responses.

By Day 6
Respond to at least two of your colleagues by comparing your assessment tool to theirs.

response 1

I enjoyed reading your post about the Hamilton Depression Rating Scale. Your scale has been around for about 70 years, and it is still used to this day. I was given the MMSE tool that was created about 25 years after your tool in 1975. The Mini‐Mental State Examination (MMSE) is one of the most known and used short screening tools for providing an overall measure of cognitive impairment in clinical, research, and community settings (Arevalo-Rodriguez et al., 2015). This test can assess a person’s memory, attention, and language (Alzheimer’s Society, (n.d.)). However, unlike your tool, it can not be used to assess the efficacy of psychopharmacologic medications because this test measures a person’s mental abilities. Since there is no cure for dementia, practitioners treat patients intending to attempt to slow the progression of dementia. However, your tool can determine how well medication works because it can track if a patient is getting better, remaining the same, or getting worse. With dementia, we can only try to slow the deterioration, but they will not get better. The Hamilton Rating Scale for Depression Essay

 

References

Alzheimer’s Society. (n.d.). The MMSE test. Retrieved September 09, 2020, from

https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/diagnosis/mmse-test

Arevalo-Rodriguez, I., Smailagic, N., Roqué I Figuls, M., Ciapponi, A., Sanchez-Perez, E.,

Giannakou, A., Pedraza, O. L., Bonfill Cosp, X., & Cullum, S. (2015). Mini-Mental State Examination (MMSE) for the detection of Alzheimer’s disease and other dementias in people with mild cognitive impairment (MCI). The Cochrane database of systematic reviews, 2015(3), CD010783. https://doi.org/10.1002/14651858.CD010783.pub2 The Hamilton Rating Scale for Depression Essay

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response 2

Thank you for your post this week. While I was aware of the existence of the Hamilton Depression Rating Scale (HAM-D) I did not realize that there are different versions of the HAM-D available. The HAM-D17 and a short HAM-D6 are both available, and according to Kieslich da Silva et al. (2019), the HAM-D6 is helpful in identifying depressive symptoms that fall outside of MDD, such as bipolar depression and bipolar depression with mixed features. A benefit according to the same study, was that the HAM-D6 is a much more brief assessment tool than the HAM-D17.
The assessment tool that I was assigned was the Mini-Mental State Exam (MMSE), which is a tool that was developed to help quickly assess the basic cognitive function by assessing the patient’s orientation, registration, calculation, and attention, as well as recall and language in a short 5-10 minute exam (Folstein et al., 1975). While the MMSE is not meant to replace a full mental status examination, it is a tool that gives providers some insight into the cognitive function of a client which may better direct the provider by giving a baseline impression before completing a full mental status examination.
Of note, according to Folstein et al. (1975) the score on the MMSE can be impacted by someone dealing with depression for whom cognitive function has declined in relation to the depression. The MMSE presents a tool that could be administered at multiple appointments to help assess whether pharmacologic or psychotherapeutic interventions for the depression has impacted the cognitive abilities. In this scenario, both the HAM-D and the MMSE could both be utilized to help assess changes to the client’s depressive symptoms. It is helpful to be aware of these different tools that are available not only for assessment and diagnosis purposes, but they also offer means by which we can measurably compare the progress of a patient over time The Hamilton Rating Scale for Depression Essay.
References
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: a practical method for grading the cognitive
state of patients for the clinician. Journal of psychiatric research, 12(3), 189-198.
Kieslich da Silva, A., Reche, M., Lima, A. F. da S., Fleck, M. P. de A., Capp, E., & Shansis, F. M. (2019). Assessment of the
psychometric properties of the 17- and 6-item Hamilton Depression Rating Scales in major depressive disorder,
bipolar depression and bipolar depression with mixed features. Journal of Psychiatric Research, 108, 84–89.
https://doi-org.ezp.waldenulibrary.org/10.1016/j.jpsychires.2018.07.009
response 3
Depression is a significant problem among elderly patients. The main issue is that depression is often overlooked as a normal aging process of underdiagnosed in the older adult population (Wheeler, 2014). Therefore, it is crucial to choose the right instruments for screening and diagnosing depression in the elderly clients. The Hamilton Depression Rating Scale (HDRS or HAM-D), which you have explored in your discussion, is one of the depression assessment tools widely used in geriatric settings. The Geriatric Depression Scale (GDS), which I presented in my discussion post, is another frequently used tool for evaluating depressive episodes in the elderly. Both the HDRS and GDS assess depressive symptoms in clinical populations. However, the GDS is a self-reported global tool for measuring depression in older adults while the HDRS rates the client’s level of depression before, during, and after treatment. As such, the GDS assesses depressive symptoms in the elderly while the HDRS moves further by quantifying the severity of depression (Rohan et al., 2018; Stone et al., 2019). The Hamilton Rating Scale for Depression Essay

You have raised a critical issue in your discussion about evaluating the effectiveness of psychotherapy. I agree with you that the HDRS rates depression in clients taking antidepressants, which allows healthcare providers to assess the effectiveness of the therapy. The GDS has also proven effective in assessing the clinical severity of depression, as well as monitoring the complex and emotional responses of patients to therapy. However, personal review of research evidence has shown that the HAM-D and Beck Depression Inventory (BDI) are the best validated tools that quantitatively assess patient’s response to treatment. Furthermore, I found a paucity of research evidence that had validated the use of both the short and long versions of the GDS in assessing the efficacy of psychopharmacologic medications (Stone et al., 2019). A key takeaway from the discussion is that the GDS is suitable for screening while the HAM-D is useful in assessing the effectiveness of treatment The Hamilton Rating Scale for Depression Essay.

References

Rohan, K., Rough, J., Evans, M., Ho, S.-Y., Meyerhoff, J., Roberts, L. M., & Vacek, P. (2018). A protocol for the Hamilton Rating Scale for Depression: Item scoring rules, rater training, and outcome accuracy with data on its application in a clinical trial. Journal of Affective Disorders, 200(6),111-118. https://doi.org/10.1016/j.jad.2016.01.051

Stone, L. E., Granier, K. L., & Segal, D. L. (2019). Geriatric Depression Scale. In D. Gu & M. Dupre (eds) Encyclopedia of Gerontology and Population Aging. Springer.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing Company The Hamilton Rating Scale for Depression Essay

Building a Health History NURS 6512 week 1 Discussion Post

Patient Overview – 38-year-old Native American pregnant female living on a reservation

Interview Summary

My interview would begin with the basics:  introducing myself to the patient and any accompanying individuals. Afterwards, I would address the patient specifically and verify the manner in which they prefer to be referred, be it formally or informally.  I would also want to insure that the visit was not rushed so I would be sure to schedule an extended amount of time, given that it is the patient’s first time meeting with me Building a Health History NURS 6512 week 1 Discussion Post.

As an APRN, I need to be aware of the factors that can effect both how I conduct myself during a visit and what the patient expects from me, their provider. Factors such as age, gender, race, ethnic group, cultural attitudes, regional differences, and socioeconomic status influence the way patients seek medical care and the way clinicians provide care. (Ball, et. al, 2010).  I believe that a knowledge of the patient and their background prior to their visit is an important piece of the puzzle. The patient’s cultural background and diversity will play a role in ensuring that I remain sensitive to her specific needs. Health beliefs and practices vary widely between cultures and ethnicities and can affect how the patient defines their current medical situation, how faith and spirituality plays a role in their care, and what level of support and input specific family members have.

In this case, the patient is a pregnant Native American woman. First, as the clinician, I would need to be aware of the specific cultural dynamics at play. For example, in the Native American culture, women play a large role in their communities because many communities are considered matrilineal. In these types of nation’s women are the decision makers and the matriarch should be included in all decisions. (Cerario, 2001).  Explanation of any procedures would be explained in detail and include all possible side effects, outcomes, and complications in an effort to build trust and show transparency Building a Health History NURS 6512 week 1 Discussion Post.

Additionally, I would ensure that I was aware of the specific practices regarding pregnancy in this population. Childbearing is viewed as part of the life cycle and therefore rhythmic. The pregnant woman’s focus at this time will be on the pregnancy and not on other issues or events that follow the pregnancy, such as child rearing or contraception. (Cerario, 2001).   The beliefs and values surrounding pregnancy, labor, delivery, postpartum, and newborn care vary from tribe to tribe and from individual to individual, and as the primary healthcare provider, it is my duty to be aware of some of the commonly practiced traditions of Native American families. (2001).

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In addition to the above practices, completing a health risk assessment also plays a large part in ensuring the appropriateness of patient care. In its simplest terms, a health risk assessment (HRA) is the evaluation of an individual’s risk of developing certain conditions based on specific factors and the role preventative medicine plays in such assessments. (Wu, 2015). As an APRN, (and an individual diagnosed with a chronic/and most likely fatal disease), the importance of preventative medicine as opposed to reactive medicine is of great importance to me Building a Health History NURS 6512 week 1 Discussion Post.

When developing my targeted questions, I attempted to combine the patient’s cultural background and the concepts surrounding the benefit of an HRA.

 

Targeted Questions:

1. What Native American tribe do you belong to?
2. Have any family members had pregnancy complications and if so, what were they?
3. Is this your first pregnancy?
4. What is your personal vision for your birth-plan?
5. What support do you require/need from your medical staff?

 

For me, at the end of the day, the treatment of the patient comes down to a holistic approach and being inattentive to  any portion only serves as a detriment to the patient I am treating Building a Health History NURS 6512 week 1 Discussion Post.

References:

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.

Cerario, S. (2001). Care of the native American woman: Strategies for Practice, Education and Research. Scholarship for the Care of Women, Childbearing Families, and Newborns. (30), 13-19. DOI:https://doi.org/10.1111/j.1552-6909.2001.tb01517.x

Wu, R. R. & Orlando, L.A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal (1079), 508-513 Building a Health History NURS 6512 week 1 Discussion Post.

Response

Thank you for your fantastic and thorough post! You have made many fantastic points. I agree that being culturally aware is important in your scenario. It appears that you have gathered some extremely useful research regarding treating Native American patients.

Effective communication increases diagnostic accuracy, patient and family understanding of treatment, and improves patient outcomes (Damm, Leiss, Habeler, & Ehrich, 2015). In this scenario, your communication tactics will be extremely important. It is important to be open and sensitive in this scenario. Many Native American individuals and Indigenous patients feel stereotyped, ignored, and not respected by non-indigenous health care providers (Roessel, n.d.). Letting this particular patient know that they are respected and in control of their care will go a long way. Building a Health History NURS 6512 week 1 Discussion Post

                                                                                                      References

Damm, L., Leiss, U., Habeler, U., & Ehrich, J. (2015). Improving care through better communication: Continuing the debate. EUROPEAN PAEDIATRIC ASSOCIATION, 167(2), 501-502. Retrieved from https://www.jpeds.com/article/S0022-3476(15)00547-8/pdf

Shannon, M., Best, D., Binns, H., Kim, J., Mazur, L., Weil, W., … Spire, P. (2005). Lead exposure in children: Prevention, detection, and management. AMERICAN ACADEMY OF PEDIATRICS, 116(4), 1036-1046. http://dx.doi.org/10.1542/peds.2005-1947 Building a Health History NURS 6512 week 1 Discussion Post

Discussion: Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

To prepare:

With the information presented in Chapter 1 of Ball et al. in mind, consider the following:

• By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
• How would your communication and interview techniques for building a health history differ with each patient?
• How might you target your questions for building a health history based on the patient’s social determinants of health?
• What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
• Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history Building a Health History NURS 6512 week 1 Discussion Post.

By Day 3 of Week 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6 of Week 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

• Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
• Suggest additional health-related risks that might be considered.
• Validate an idea with your own experience and additional research. Building a Health History NURS 6512 week 1 Discussion Post

BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion

Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.

Module 2: Functional Assessments and Assessment Tools

Week 2: Week 2: Functional Assessments and Cultural and Diversity Awareness in Health Assessment

Discussion: Diversity and Health Assessments

Initial Post: Patient Profiles – BK is a 16-year-old Caucasian female

Tanya SchellB   is a 16-year-old Caucasian female – NURS 6512 week 2 discussion

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As an Advances Practice Nurse (APN), it is essential to the success of the patient outcomes to become culturally competent. The APN will provide services to many different cultures throughout their career. According to Ball, et al, (2015), each patient should be treated according to their culture religious, socioeconomic, and personal beliefs. A competent and successful healthcare provider will be able to offer competent care to people belonging to other cultures different from their own (Corona, et al, 2017) when educating themselves on the different cultures and their specific needs. Seeking out cultural training is one way to be successful in the delivery of patient-specific healthcare. Culturally competent healthcare providers can adapt to the unique needs of patients from various cultural backgrounds, developing a trusting relationship between the healthcare provider and the patient (Ball, Dains, Flynn, Solomon, & Stewart, 2015). In order to build a trusting provider-patient working relationship, it begins with the provider being knowledgeable of the patient’s specific culture. Avoiding stereotypes is imperative in succeeding in positive patient outcomes BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion.

In this patient scenario, BK is a 16-year-old Caucasian female, who presents to the clinic for an annual well-child visit. BK doesn’t make eye contact with the APN, she is obese and currently not on medications. BK is accompanied by her Grandmother who has concerns and believes BK is now acting strange, staying in her room all the time, and refusing to do all the things BK use to enjoy like singing in the youth choir at their church. The grandmother is fearful that BK might be using drugs and is requesting a drug screen since BK’s mother has a history of drug use and is currently incarcerated. It appears that BK has lived with the grandmother for some time since the grandmother can see a change in BK. BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion

Being sensitive on the subjects of her weight, and her views on her mother. Teenage girls are very sensitive about their weight and might have a hard time opening up about their feelings regarding their weight. All teenagers, but especially girls need extra support, guidance, and nurturing from their mothers and fathers. Since BK’s mother is not currently in her life, this may be an emotional trigger for BK to discuss. Asking questions specific to her spirituality will help the APN understand why BK suddenly stopped participating in the youth choir at church. Finding out about how BK feels about living with her grandmother and if they have any socioeconomic issues or concerns that can be addressed by the APN or referred to another source for assistance. Engaging in conversation about BK’s friends, activities, and risky behaviors also helps the APN learn BK’s lifestyle and any cultural issues BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion.

 

Targeted Questions

1. Have you had anything traumatic happen to you? Have you ever participated in counseling?
2. How do you feel about your mother not being around and her drug situation? What do you believe is the cause of drug use by your mother? How do you feel about drugs?
3. How high is your self-esteem? Do you have thoughts of self-harm? Do you find joy in your life?
4. What do you see has changed in your life? Is your life satisfying?
5. Do you attend church? Do you feel that you are a spiritual person?
6. What do you and your friends do for fun? Have you participated in any risky activities with friends? Drugs, Alcohol, skipping school?
7. What do you normally eat during the week? Do you feel that you are at a healthy weight?  What is your goal weight?
8. Is there anything else you want to talk about today?
9. What else can I help you with today?

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Corona, R., Rodríguez, V. M., McDonald, S. E., Velazquez, E., Rodríguez, A., & Fuentes, V. E. (2017). Associations between cultural stressors, cultural values, and Latina/o college students’ mental health. Journal of youth and adolescence, 46(1), 63-77

Lonneman, W. (2015). Teaching strategies to increase cultural awareness in nursing students. Nurse educator, 40(6), 285-288 BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion.

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By Day 6 of Week 2

Respond on or before Day 6 on 2 different days to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.

 

response

I enjoyed reading your post and getting your perspective on treatment of BK. I especially liked how you made sure to focus on her spirituality that you focused on the importance of shying away from things that may be emotional triggers for her, (her weight; her mother). While I think that those issues are of great importance, I believe that it would benefit more to build trust and focus on those issues at a later appointment; possibly at an appointment where she is alone.

Ensuring that we, as APRNs, address the individual as well as their culture. In this case, the fact that the patient’s mother has a history of drug abuse is definitely a risk factor, but should not be the only piece of the puzzle when evaluating the patient for potential risk behaviors. An individual may belong to many subgroups and that the behaviors and attitudes of a subgroup can override the impact of the cultural values of the larger group (Ball et al, 2019).

Screening for depression in this particular patient will also be of great importance. When doing so, it is imperative that screening is be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (Siu, 2016). Treatment of this particular patient should occur over multiple visits and her completed treatment plan should not be based off of the single visit.

 

References

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.

Siu, A.  (2016).  US Preventive Services Task Force Pediatrics.  Screening for Depression in Children and Adolescents 137 (3) e20154467; DOI: 10.1542/peds.2015-4467 BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion

response 2

Patients who are in this age group are going through a lot in life. Stressors includes school, part time job, family, hormonal changes, body image disturbance, peer pressure, introduction to substances, etc. It may take a longer time or a few sessions to build rapport with a teenager, especially one of the opposite sexes. During the physical the practitioner would have to examine the patient’s genitalia. So, if the practitioner is a woman and the patient is a male, or visa versa, there will be a chance the patient will feel uncomfortable and not agree with the total health assessment. A teen client can be a master at putting up the invisible force field while pushing our buttons or telling us what we want to hear and side-stepping responsibility. (Selekman, 2020). Once the teen feels pressured or obligated to do something against their will, the patient will shut down and either be untruthful or not answer the question.

Teens face an especially hard time when the practitioners ask them about their sexual orientation, sexual partners and if they think they have been exposed to any sexual transmitted diseases. As part of the physical, this patient will be asked about her last menstrual cycle, the flow, cramps, and any abnormal discharge. Also, a pelvic exam will be done to test for STDs and possible cervical disease. If the patient has never had any sexual activity, this procedure can be especially traumatic. A speculum is inserted inside her, this procedure is invasive and can be painful. Recent studies show that if the patient is not sexually active, this exam is not deemed necessary. Bimanual pelvic exams and Pap tests used to be standard parts of annual gynecological checkups, but leading professional associations no longer recommend them for most younger patients. (Vaughn, 2020).

Many teen girls deal with body image disturbance. All they see on television are skinny supermodel like movie stars. Taking this ideal image as something that is normal, so if they differ and especially if they are overweight or obese, they will feel a sense of not belonging to the norm. This female patient is obese, she currently does not have any medical issues and not taking any meds. But, to her grandma she is acting strange and staying in her room and refusing to do extracurricular activities like singing in her youth choir at church. The grandmother disclosed that the patient’s mother has a history of drug use and is currently incarcerated. There can be an arranged of possibility with this patient. She is in a current stage of life where she might feel more comfortable being alone, and this is totally normal. Or, the grandmother is correct, and she may be exposed to illegal substances and is currently using drugs. Ethically and legally a drug test should not be ordered just because the grandma wants it done on the patient. The practitioner needs the consent of the patient, even though she is a minor. We as practitioners cannot force the patient to do the test unless it is an emergency BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion.

A psych social can also be done if the practitioner deems it is necessary because during this period the patient can develop depression or anxiety related to her many stressors in life. Untreated depression and anxiety can lead to self-harm, self-medicating with substances or worst-case scenario, suicide. The practitioner can refer the patient to a therapist or psychiatrist. Teens sometimes feel like multiple stressors is too much for them to handle and they rather not deal with it. Carefully monitoring the patient and if she exhibits any abnormal behavior is a good indicator of potential self-harm.

 

References

Selekman, M. (2020). How to make teen therapy engaging. Retrieved on June 12, 2020 from https://www.psychotherapynetworker.org/blog/details/405/creating-a-therapeutic-alliance-with-the-troubled-teen

Vaughn, E. (2020). Teen girls do not need routine pelvic exams. Why are doctors doing so many? Retrieved on June 12, 2020 from https://www.npr.org/sections/health-shots/2020/01/09/794991658/teen-girls-dont-need-routine-pelvic-exams-why-are-doctors-doing-so-many BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion

response 3

BK being in her teens, the NP must find ways of conversing with her.  During the adolescence period, teens like privacy, and therefore she might not speak freely with the NP.  Forming a trusting relationship is key and can allow BK to confide in the NP on what is presently going on in her life.   The NP should make BK feel comfortable and not ask questions that may be deemed as intrusive per Klein et al. (2020).  An adolescent patient is likely to disclose sensitive information when confidentiality is guaranteed per  Klein et al. (2020) and therefore providers must offer confidential screening and counseling.

The provider can perform a short psychosocial screening which can include existing stressors, whether BK has a confidant and how her experience is at school.  Teens older than 12 years of age should also be screened for major depressive disorder according to Spithoven et al.(2017).    Klein et al. (2020) also explain that teens with a BMI of 95^th percentile and higher can be referred for a comprehensive behavioral intervention.  It is only after the NP gains the trust of BK, can she then talk about BK’s feelings and how the incarceration of her mother has influenced her life.

Adolescents have stressors that the NP can focus on during the initial well visit.  Threats to the well being of teenagers can both be experimental and psychosocial stressors per Klein et al. (2020).  According to Klein et al. (2020), this includes school, home, activities, drugs, emotions or eating, sexuality, strengths and safety.    The NP must not only gather a psychosocial history but also emphasize on BK’s strengths to deter the feeling of shame per Klein et al. (2020).    A provider can also talk about digital literacy and how to have boundary settings while online as Klein et al. (2020) advices us.  The NP should not only focus on the patient’s physical being but also in general.  Questions to ask can include what BK likes to do, what she is most proud of, whether she has friends.  More questions include whether she has been feeling stressed, any trouble sleeping, any feeling of being down, sad or depressed, any thoughts of hurting herself, or if she has had any attempts BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion.

Reference

Klein, D. A., Paradise, S. L., & Landis, C. A. (2020). Screening and Counseling Adolescents and Young Adults: A Framework for Comprehensive Care. American Family Physician, 101(3), 147–158.

Spithoven, A., Lodder, G., Goossens, L., Bijttebier, P., Bastin, M., Verhagen, M., & Scholte, R. (2017). Adolescents’ Loneliness and Depression Associated with Friendship Experiences and Well-Being: A Person-Centered Approach. Journal of Youth & Adolescence, 46(2), 429–441. https://doi-org.ezp.waldenulibrary.org/10.1007/s10964-016-0478-2 BK is a 16-year-old Caucasian female – NURS 6512 week 2 discussion

AG is a 54-year-old Caucasian male – NURS 6512 discussion post

Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.

WK 2 Health Assmt.   Discussion.

AG is a 54-year-old Caucasian male who was referred to your clinic to establish care after a recent hospitalization after having a seizure related to alcohol withdrawal. He has hypertension and a history of alcohol and cocaine abuse. He is homeless and is currently living at a local homeless shelter. He reports that he is out of his amlodipine 10 mg which he takes for hypertension. He reports he is abstaining from alcohol and cocaine but needs to smoke cigarettes to calm down since he is not drinking anymore AG is a 54-year-old Caucasian male – NURS 6512 discussion post.

Socio-Economic, Spiritual, Lifestyle and Cultural Factors

Ball et al. (2019), explain that patients age differently and their knowledge, cognitive abilities, personality, and experience will influence how the interview is conducted by a provider.  There could be a multitude of reasons as to why an older adult can become homeless.  This includes unemployment due to corporate age discrimination as told by Murphy and Eghaneyan (2018).  AG’s drug and alcohol use could be a reason as to why he lost his employment and due to financial constrains, was unable to pay rent or mortgage.  It is the responsibility of the nurse practitioner to gather information from the patient and not make assumptions about situations.  The socioeconomic factors we are looking at are employment, education, and income per Coogle and Owens (2015).

An individual’s income plays an important role in the determinant of health according to Mullen (2015). Having a higher income enables better nutrition, housing, health care, and recreation per Tsai (2018). On the other hand,  poverty has a strong detrimental effect on health and is normally associated with unhealthy or risky behaviors as reported by Tsai (2018).  People with low income have been observed to have more association with the consumption of unhealthy goods, like tobacco, alcohol and illicit drug use according to Tsai (2018). AG has no income and therefore has fewer chances of seeking healthcare resources or preventative services.  These services could mean the difference between having a manageable health condition versus late stage multiple diagnosis and treatment.   AG smokes, uses drugs and alcohol which shows his lack of health promoting behaviors AG is a 54-year-old Caucasian male – NURS 6512 discussion post.

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Education is one of the focal determinants of health and is an indicator of a person’s socio-economic status per Mullen (2015).  People who are better educated have fewer morbidities than their counterparts according to Hook and Markus (2020).  We do not know AG’s level of education and therefore we cannot draw any conclusions.  AG’s lifestyle is contributing to his present status which is having a negative effect on his health.   From his chosen lifestyle, AG can end up having a heart attack or death from uncontrolled hypertension and the use of illicit drugs.  Cigarette smoking can also increase cardiovascular problems as well as cause cancer.

AG needs support and education in the management of his illness.  Due to the socioeconomic factors unfolding in his life, he may become depressed and without help, may contemplate suicide.  Inquiring about AG’s mood like depression or anxiety can allow the NP to analyze what resources are appropriate.  There is no mention of any religious preferences and this could be a question that the NP can ask during patient interviews.

Drug users and homeless individuals experience severe health inequalities and barriers to accessing healthcare.   It is the duty of the healthcare workers to change their perception of others and be receptive to other people’s cultures as O’Donnell et al. (2019) explain. AG is a 54-year-old Caucasian male – NURS 6512 discussion post

Sensitive Issues while Interacting with Patient

AG may have reservations about speaking about his adversities with a new provider for fear of being judged or prejudice.   As a nurse practitioner, one should be cautious about how questions are posed to the patient as Coogle and Owens (2015) explain.  A tone that is accusatory will not yield pertinent information.   The NP should make sure that they are not passing judgement or being prejudice against any patient that they encounter per Ball et al. (2019).  The nurse practitioner should listen carefully to AG during the information gathering process AG is a 54-year-old Caucasian male – NURS 6512 discussion post.  The nurse practitioner should also be careful of the non-verbal cues they present.  How a clinician controls their emotions is also a strong communication skill that is very important during the interview process.

AG did not choose a healthy lifestyle and therefore the nurse practitioner can offer AG resources that can aid him in his health quest.  Smoking cessation resources should also be offered when AG is ready to give up the unhealthy habit.  At this time, it is imperative that the clinician offers full support and not force AG to give up any behaviors unwillingly.   The nurse practitioner does not know anything about AG and therefore must use the RESPECT model as adviced by Ball et al. (2019).

Questions pertaining to why he chose to use drugs and alcohol should be asked respectfully without any preformed notions from the NP per Ball et al. (2019).   A trusting relationship must be formed with AG who may probably be embarrassed about the life choices he has made.  AG is in his early fifties and mid-life crisis is also a concern at this time and therefore the NP must not make him feel like he is a  failure.  Instead AG needs reassurance, support, guidance and with the help of the NP, he can set a goal that is attainable per Coogle and Owens (2015).

Questions to ask AG

Part of the information gathering involves asking the patient his allergies and the reactions experienced, the patient’s family history of illnesses, any previous surgeries to name a few.

1. Have you had any  other previous hospitalizations including any mental health stay
2. Can you please tell me how you ended up staying at the shelter or being homeless
3. When did you start using cocaine, alcohol and tobacco substances
4. What were your last employment and the duration
5. What is your highest level of education
6. Do you have any religious or cultural preferences, that we need to put in place AG is a 54-year-old Caucasian male – NURS 6512 discussion post
7. Do you ever experience feelings of hopelessness, depression, sadness
8. Are there are resources that you would like to have access to
9. Is there anything else you think we might be able to assist you with

AG should have an opportunity to ask any questions or clarify information.  Resources should be offered by the nurse practitioner who can also put AG in contact with a social worker for further commendations.

 

References

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.

Coogle, C., & Owens, M. (2015). Screening and Brief Intervention for Alcohol Misuse in Older Adults: Training Outcomes Among Physicians and Other Healthcare Practitioners in Community-Based Settings. Community Mental Health Journal, 51(5), 546–553. https://doi-org.ezp.waldenulibrary.org/10.1007/s10597-014-9804-x

Hook, C. J., & Rose Markus, H. (2020). Health in the United States: Are Appeals to Choice and Personal Responsibility Making Americans Sick? Perspectives on Psychological Science, 15(3), 643–664. https://doi-org.ezp.waldenulibrary.org/10.1177/1745691619896252

Mullen, J. (2015). Living Longer Better: A Call to Action to Promote the Health of Older Adults and Their Communities. Journal of Public Health Management & Practice, 21(4), 410–412. https://doi-org.ezp.waldenulibrary.org/10.1097/PHH.0000000000000280

Murphy, E. R., & Eghaneyan, B. H. (2018). Understanding the Phenomenon of Older Adult Homelessness in North America: A Qualitative Interpretive Meta-Synthesis. British Journal of Social Work, 48(8), 2361–2380. https://doi-org.ezp.waldenulibrary.org/10.1093/bjsw/bcx163

O’Donnell, P., Tierney, E., O’Carroll, A., Nurse, D., & MacFarlane, A. (2016). Exploring levers and barriers to accessing primary care for marginalised groups and identifying their priorities for primary care provision: a participatory learning and action research study. International Journal for Equity in Health, 15(1), 197.

Tsai, J. (2018). Lifetime and 1-year prevalence of homelessness in the US population: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Journal of Public Health, 40(1), 65–74. https://doi-org.ezp.waldenulibrary.org/10.1093/pubmed/fdx034 AG is a 54-year-old Caucasian male – NURS 6512 discussion post

By Day 6 of Week 2

Respond on or before Day 6 on 2 different days to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.

response

Great post! I thought that you addressed a situation that had several layers of difficulty extremely well. It’s clear that you were very aware of the cultural and socioeconomic factors at play. Treating a patient with a history of ETOH abuse is difficult in itself, but given that fact that the patient is currently homeless adds another hurdle for the patient as well as the practitioner. I especially enjoyed your acknowledgment of the sensitivity of the patient’s situation and that you used that knowledge to form well thought out and pointed questions.

Given the prevalence of mental health and substance abuse in the homeless population, I do think that establishing a timeline will be extremely important in the treatment of this patient. Did the patient begin drinking heavily before or after he was homeless? Had he been diagnosed with any mental health disorder and at what age?

Research estimates that 38 percent of homeless people are alcohol dependent and that their living conditions made it more difficult to remain sober and achieve stability. That makes appropriate treatment and follow up an important part of ensuring this patient is successful with their sobriety.  Effective communication is always key, but maybe more so in complex and difficult situations. Establishing a positive patient relationship depends on communication built on courtesy, comfort, connection, and confirmation. Building a history is important, of course, but building trust from the start will help to ensure that the patient is open and honest and in turn, or treatment will be more effective. AG is a 54-year-old Caucasian male – NURS 6512 discussion post

 

References

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.

Murray, K. (2019). Homeless Alcoholism. Retrieved June 13, 2020 from https://www.alcoholrehabguide.org/resources/homeless-alcoholism/#sources AG is a 54-year-old Caucasian male – NURS 6512 discussion post

Discussion: Diversity and Health Assessments

Randall’s statements sparked a great deal of controversy and debate; however, they emphasize an underlying reality in the healthcare field: different populations, cultures, and groups have diverse beliefs and practices that impact their health. Nurses and healthcare professionals should be aware of this reality and adapt their health assessment techniques and recommendations to accommodate diversity.

In this Discussion, you will consider different socioeconomic, spiritual, lifestyle, and other cultural factors that should be taken into considerations when building a health history for patients with diverse backgrounds. Your Instructor will assign a case study to you for this Discussion.

To prepare:

• Reflect on your experiences as a nurse and on the information provided in this week’s Learning Resources on diversity issues in health assessments.
• By Day 1 of this week, you will be assigned a case study by your Instructor. Note: Please see the “Course Announcements” section of the classroom for your case study assignment.
• Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient assigned to you.
• Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
• Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?AG is a 54-year-old Caucasian male – NURS 6512 discussion post
  

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By Day 3 of Week 2

Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6 of Week 2

Respond on or before Day 6 on 2 different days to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why AG is a 54-year-old Caucasian male – NURS 6512 discussion post.

Week 2 Discussion: Diversity

Case Study 2:

AG is a 54-year-old Caucasian male who was referred to the clinic to establish care after a recent hospitalization after having a seizure related to alcohol withdrawal. He has hypertension and a history of alcohol and cocaine abuse. He is homeless and is currently living at a local homeless shelter. He reports that he is out of his amlodipine 10 mg which he takes for hypertension. He reports he is abstaining from alcohol and cocaine but needs to smoke cigarettes to calm down since he is not drinking anymore.

 

The socioeconomic issues affecting AG is homelessness, finances, and lack of adequate health care. During the initial interview, I would assess for financial income and the ability to secure stable long term housing. Establish if any family or friends are involved in his life, ask the patient if he has been to rehab in the past and if he is willing to go to inpatient rehab to stabilize and receive counseling and coping strategies (Cuevas & Whitiney, 2019). Ask the patient what are his plans, and how long he plans to stay at the shelter because accommodation is only temporary and safe housing is to be included in planning (Manning & Greenwood, 2019). AG is a 54-year-old Caucasian male – NURS 6512 discussion post

The patient’s perceived quality of life is based on his current lifestyle which includes substance abuse, lack of stable housing. AG is a 54-year-old caucasian male and sensitivity to cultural differences to avoid miscommunication is to be considered in cultural factors, and history of substance abuse and seizures he should be assessed for cognitive function. Issues I need to be sensitive about are his finances, be sensitive in the questioning line of income, does he have an income from unemployment, SSI, or disability, does he he have health insurance or the ability to pay for medications and food. Family relations can be a source of anxiety to some individuals, I will be sensitive to line of questioning on family, friends, and community relations if he has any support or in contact with any members. Religion and faith-based beliefs can create a barrier to communication and the ability to accept some interventions. As far as his substance abuse I would ask about when last he used, how long he has been using, identify his triggers to reduce relapse. I will be sensitive to his personal space and mode of communication, ask what is his preferred mode of communication, language, what name he wants to be called (Ball, Dains, Flynn, Solomon, & Stewart, 2019) AG is a 54-year-old Caucasian male – NURS 6512 discussion post.

Targeted questions to the patient to build his health history and to assess his health risks include

1. Medical and familial history, when was he first diagnosed with hypertension, and family history of cardiac disease. What medications he currently take and when was his last dose. Where did he last seek medical attention?

2. Level of education and any work skills, this is to assess his level of comprehension and processing of information to be exchanged.

3. Depression screening tool to assess for level of anxiety, what does he mean he needs a cigarette to calm down, how many does he smoke daily, what are his triggers?

4. History of substance abuse, what are his substances of choice, did he ever attempt to quit before, did he ever have the professional help to quit. How much money does he usually spend on his habit?

5. Well- maintenance evaluation, when last did he have physical, including prostrate screening, colorectal screening, diabetes risk assessment, cardiovascular disease risk assessment, and STD risk assessment screening?

6. Any history of abuse or trauma, any history military service to rule out PTSD

7. Vaccination history for immunity against community-acquired infections because of his housing disposition.

 

References

Ball, J. W., Daines, 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.

Cuevas, R., & Whitney, G. (2019). Better Together: An Early Head Start Partnership Supporting Families in Recovery Experiencing Homelessness. ZERO TO THREE, 39(4), 29–34.

Manning, R. M., & Greenwood, R. M. (2019). Recovery in Homelessness: The Influence of Choice and Mastery on Physical Health, Psychiatric Symptoms, Alcohol and Drug Use, and Community Integration. Psychiatric Rehabilitation Journal, 42(2), 147–157. https://doi-org.ezp.waldenulibrary.org/10.1037/prj0000350

response

Your post categorically addresses the socioeconomic factors that affect this patient. According to Health People (2020), race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health(“Disparities,” n.d.). The targeted questions are structured to provide detailed information that will assist in the patient’s care plan. Numerous studies have shown that the homeless seek treatment late in their disease process; fall out of disease management plan including non-adherence to prescribed medications,  and have a frequent  habit of visiting the Emergency Room and Inpatient services AG is a 54-year-old Caucasian male – NURS 6512 discussion post. It is important for clinicians to inquire about readiness to change and the resources available for this patient. Examples of questions that bring forth the need for change are: What are the benefits of staying sober?; Have you ever thought of committing suicide?”; If you did want to make a change, how would you go about it?” (Cooper, 2016). Such inquiry elicits the individual’s commitment to making change.

Cooper, D. B. (2016). Intervention in mental health-substance use. CRC Press.

Disparities. (n.d.). Healthy People 2020 |. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities AG is a 54-year-old Caucasian male – NURS 6512 discussion post

Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions

Comprehensive SOAP Template 

Patient Initials: J.R                  Age: 8 years                Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC):  Rash on the face, arms, and trunk accompanied by itching. (Fig 9.80 Ball et al., 2019).

History of Present Illness (HPI): J.R is an 8-year-old Caucasian patient presented with complaints of a pruritic rash. The patient’s caregiver reports that the rash appeared two days ago when the child was in school. The rash first appeared on the scalp and the face and progressed to upper limbs and the trunk on the same day. The mother states that the rash started as small red spots, which rapidly progressed to small clear pimples with a surrounding reddish area within 12 hours. The caregiver reports that this is the first episode that the child developed the characteristic rash. She states that the child has had a mild increase in body temperature, is inactive, and has a decreased appetite. The patient states that scratching the rash triggers pruritus in his entire body. The caregiver reports that she had administered the child with Chlortrimeton syrup to lower the fever and reduce the itchiness, which had a moderate impact on the pruritus but did not control the spread and appearance of the rash. The patient denies any history of insect bite. However, the child reports that a classmate had developed a similar rash two weeks ago Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

Medications: OTC Chlortrimeton syrup 10 mL three times a day.

Allergies: No known food, drug, or environmental allergies.

Past Medical History (PMH): J.R. had a history of hospitalization at the age of 3 years due to severe pneumonia, which was managed with IV antibiotics and oxygen therapy.  No history of chronic illnesses.

Past Surgical History (PSH): The patient had a minor surgery, Incision, and Drainage, in Sep-2019 due to an abscess on his right thigh.

Sexual/Reproductive History: The patient is sexually inactive.

Personal/Social History: J.R. lives with his parents and two siblings in Salt Lake City, Utah. He is in 3^rd grade and has a great academic performance. He states that his favorite subjects are science and art. He enjoys drawing and painting and is part of the Art club in school. The patient also states that he enjoys watching animation movies and playing video games when indoors. The mother reports that the child has no difficulties in performing ADL’s. The patient has an active lifestyle and enjoys playing soccer and swimming. He plays soccer in school and is part of the junior soccer team. He takes three meals a day with snacks between meals. The mother reports that he provides the child with a balanced diet with plenty of fruits, real fruit juices, and milk. The patient reports no eating difficulties. He sleeps approximately 10 hours a day and denies having sleeping difficulties Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

Immunization History: The patient’s vaccination history is up-to-date. The last Influenza shot was 4 months ago.

Significant Family History: Maternal grandmother died at the age of 79 due to Lung cancer. The paternal grandfather has Hypertension and Type 2 Diabetes. Parents are alive and well. The elder sibling, 13-year-old, has Eczema.

Lifestyle:

J.R.’s mother denies engaging in any cultural practices or using herbs. The patient is economically supported by his father and mother. The father is an accountant while the mother is a high school teacher. The mother reports that she controls TV-time and supervises what the child watches on T.V. J.R. reports that he puts on protective gear when swimming and playing soccer. He also states that he has several friends, both from school and the neighborhood.

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Review of Systems:

General: Genera body malaise and low-grade fever. Denies recent weight changes

HEENT: Head: Denies a history of headache. Eyes: Denies changes in vision, eye reddening, photophobia, or excessive lacrimation. The last eye-checkup 2 years ago, no abnormalities detected. Ear: Denies hearing loss, ear discharge, or pain behind the ear. Nose: Denies nasal discharge, epistaxis, facial tenderness, or history of allergic rhinitis. Reports an intact sense of smell.  Throat: Denies dental pain, bleeding gums, or tongue soreness. Denies difficulties in swallowing, sore throat, or hoarseness Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

Neck: Denies neck pain or stiffness.

Breasts: Denies breast mass or tenderness.

Respiratory: Denies cough, sputum production, shortness of breath, exertional dyspnea, or wheezing. History of Severe pneumonia 2015.

Cardiovascular/Peripheral Vascular: Denies edema, chest pain, palpitations, shortness of breath, exertional dyspnea, or bluish discoloration of lips or fingers.

Gastrointestinal: Denies experiencing nausea, vomiting, abdominal discomfort, or changes in elimination pattern.

Genitourinary: Denies urinary frequency, urgency, dysuria, or blood in the urine. Denies penile discharge.

Musculoskeletal: Denies difficulties in movement, muscle pain, joint pain, or joint stiffness.

Psychiatric: No history of anxiety, depression, or child conduct disorders.

Neurological: Denies history of headache, dizziness, syncope, seizures, tingling sensations, muscle weakness, or gait/posture abnormalities.

Skin: Pruritic red rash (refer to HPI).

Hematologic: No history of blood transfusion.

Endocrine: Denies cold/heat intolerance, acute thirst, increased hunger, or excessive sweating Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

Allergic/Immunologic: No history of allergic reactions.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Ht.- 2’6, Wt.- 52.9 pounds RR- 18, HR-94, BP-104/65, and Temp- 99.86F

General: Patient is sick-looking with no acute distress. Maintains and upright posture. Neat and well-groomed. Patient is Alert and maintains eye-contact.

HEENT: Head is Normocephalic and symmetrical. The sclera is white and conjunctiva pink.

PERRLA, Tympanic membranes intact. Nasal septum well-aligned. Mucous membranes pink and moist. The tongue is midline; 2 missing teeth. Tonsillar glands non-inflamed.

Neck: Trachea midline, No Thyroid gland enlargement.

Chest/Lungs: Chest rise and falls uniformly on breathing in and out. Respirations smooth with no use of accessory muscles. Chest clear on auscultation.

Heart/Peripheral Vascular: No JVD or edema. RRR with no murmurs, friction rubs or

S gallop.  Pulses+2 bilateral pedal and +2 radial

Abdomen: Flat and smooth. BS-normoactive in all quadrants. No tenderness, masses, or organomegaly on palpation.

Genital/Rectal: Normal male genitalia. No anal fissures or tears present.

Musculoskeletal: Muscle strength 5/5

Neurological: CNs-intact, DTRs-intact

Skin: Papular and vesicular lesions present on the scalp, face, upper extremities, and trunk. The lesions are elevated and circumscribed on the superficial layer of the skin. The skin around the vesicles is erythematous. The erythematous Lesions are filled with clear fluid and are < 1 cm in diameter and appear in clusters (Fig 9.80 Ball et al., 2019) Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

ASSESSMENT:  

Priority Diagnosis

Chickenpox: Chickenpox, also known as Varicella, is an acute and highly communicable disease common in children and young adults. It is caused by the varicella-zoster virus (VZV) (Ball et al., 2019). The VZV is spread by droplets from the upper respiratory tract or discharges of ruptured lesions on the skin (Kennedy & Gershon, 2018). It has an incubation period of 14 – 21 days. It has a communicability period of 1 to 2 days before the onset of the rash and until lesions have crusted over.

Varicella results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the scalp and then spreads to the face, chest, back, and upper extremities (Ball et al., 2019). It begins with small, erythematous macules that rapidly progress over 12-14 hours to papules and then clear vesicles (Gershon et al., 2015). The vesicular stage is often accompanied by intense pruritus.

The skin rash is accompanied by low-grade fever, fatigue, pharyngitis, and headaches, lasting five to seven days (Gershon et al., 2015).  However, childhood varicella does not begin with a prodromal phase but starts with the onset of exanthema. Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions

Chickenpox is the priority diagnosis based on pertinent positive findings of red spots that progressed into erythematous vesicles and pruritus. Besides,  a history of rash on the scalp and face and spread to upper extremities and trunk. Other positive findings include a low-grade fever, general malaise, and loss of appetite Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

Differential Diagnoses

Nun-bullous Impetigo: Impetigo is a common and highly contagious, superficial skin infection that manifests with either a bullous or non-bullous appearance (Hartman-Adams, Banvard & Juckett, 2014). Non-bullous impetigo on children begins as a single lesion typically presenting as a red macule or papule. This quickly progresses into a vesicle. The vesicle ruptures, causing erosion and the vesicular contents dry to form a characteristic honey-colored crust (Ball et al., 2019). The non-bullous impetigo commonly occurs on the face or extremities. Individuals often have mild regional lymphadenopathy, but pharyngitis is absent (Hartman-Adams, Banvard & Juckett, 2014).

Nun-bullous impetigo is a differential diagnosis based on a positive history of the appearance of small red spots, which quickly progressed to vesicles within 12 hours. However, the presence of fever, erythematous vesicles, and absence of crusts rules out non-bullous impetigo s the priority diagnosis.

Erythema Multiforme: Erythema Multiforme (E.M.) is an acute and self-limited skin condition considered a type IV hypersensitivity reaction. It is associated with certain infections, medications, and other triggers (Hafsi & Badri, 2019). It present with pink macules with purple central papules. E.M. is categorized into E.M. minor and major. E.M. minor is characterized by a localized eruption of the skin with minimal or no mucosal involvement (Hafsi & Badri, 2019). The papules evolve into iris lesions that appear within 72-hours and begin on the extremities. The lesions remain fixed for at least 7 days and then start to heal. E.M. major manifests with localized eruptions that involve one or more mucous membranes (Hafsi & Badri, 2019). E.M. is a differential diagnosis based on the presence of red spots in the patient. However, the history of the spread of lesions makes E.M. an unlikely diagnosis Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

Dermatitis herpetiformis: Dermatitis herpetiformis manifest with clustered excoriations, erythematous, urticarial plaques, and papules with vesicles (Antiga & Caproni, 2015). The dermatitis herpetiformis lesions are typically located on the extensor surfaces of the elbows, knees, buttocks, and trunk (Antiga & Caproni, 2015). It is extremely pruritic, and the vesicles are get excoriated to erosions. (Antiga & Caproni, 2015) This is a differential diagnosis based on positive findings of pruritic erythematous papular and vesicular lesions on the trunk. Pertinent negative findings include clustered excoriations and the presence of lesions on the scalp, face, and upper extremities. Besides, the presence of fever, malaise, and loss of appetite rules out dermatitis herpetiformis as a primary diagnosis.

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References

Antiga, E., & Caproni, M. (2015). The diagnosis and treatment of dermatitis herpetiformis. Clinical, cosmetic and investigational dermatology, 8, 257–265. https://doi.org/10.2147/CCID.S69127

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.

Gershon, A. A., Breuer, J., Cohen, J. I., Cohrs, R. J., Gershon, M. D., Gilden, D., Grose, C., Hambleton, S., Kennedy, P. G., Oxman, M. N., Seward, J. F., & Yamanishi, K. (2015). Varicella-zoster virus infection. Nature reviews. Disease primers, 1, 15016. https://doi.org/10.1038/nrdp.2015.16

Hafsi, W., & Badri, T. (2019). Erythema Multiforme. In StatPearls [Internet]. StatPearls Publishing.

Hartman-Adams, H., Banvard, C., & Juckett, G. (2014). Impetigo: diagnosis and treatment. American family physician, 90(4), 229-235.

Kennedy, P., & Gershon, A. A. (2018). Clinical Features of Varicella-Zoster Virus Infection. Viruses, 10(11), 609. https://doi.org/10.3390/v10110609 Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.

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 Comprehensive SOAP Lab Assignment: Differential Diagnosis for Skin Conditions.