NURS 6512 Week 4 Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions Sample Essay

SUBJECTIVE DATA:

 

Chief Complaint (CC): “itchy, scaly area in my chin”

 

History of Present Illness (HPI): R.R. is a 55-year-old client who visited the facility with complaints of an itchy, scaly area in his chin. The client reported that he noticed abnormal skin pigmentation over the last two months. He thought that it would heal on its own, which has not been the case. According to R.R., the pigmentation is scaly, and itchy, with brown-to-black pigmentations. The skin problem has affected his identity. He has not applied any medication to treat the skin problem. Exposure to hot temperatures worsens the itchiness.

 

Medications: None

 

Allergies: R.R. denied any history of food, drug, or environmental allergies

 

Past Medical History (PMH): R.R. has a history of hospitalization three years ago due to meningitis. He was diagnosed with hypertension a year ago and has been managing it with medications and lifestyle modifications. He reports that his blood pressure is controlled. His immunization records are up-to-date.

 

Past Surgical History (PSH): R.R. has no history of surgical procedures.

 

Sexual/Reproductive History: R.R. is married. He has two children. He denied a history of sexually transmitted infections. His last prostate examination was two years ago, which was normal. He denied dysuria, urgency, and frequency. He identifies himself as heterosexual.

 

Personal/Social History: R.R. works as a truck driver. He is married with two children. They live in an apartment they bought ten years ago. R.R. stopped smoking a year ago. He takes three bottles of alcohol during weekends. He does not use marijuana. R.R. spends his leisure time with his family. He considers his family as a source of his social support. R.R. wears a seatbelt when driving. Their home has smoke detectors.

 

Health Maintenance: R.R. rarely engages in active physical activities. He checks his blood pressure regularly. His last prostate cancer exam was two years ago.

 

Immunization History: R.R.’s immunization record is up-to-date.

 

Significant Family History: R.R.’s father died at the age of 81 years old because of prostate cancer. His mother died at the age of 67 due to heart disease. His paternal grandfather died of hypertension. His maternal grandmother died of major depression. R.R.’s brother has alcohol use disorder while his sister was recently diagnosed with major depression.

NURS 6512 Week 4 Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions Sample Essay

NURS 6512 Week 4 Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions Sample Essay

Patient Information: R.S, 50-year-old male

Subjective

CC: Nasal congestion as well as itching for the last 5 days

HPI: R.S is a 50-year-old male that came to the unit with complaints of nasal congestion, rhinorrhea, sneezing, itchy nose, postnasal discharge, and itching ears and nose for the last 5 days. The patient reported using Mucinex medication to help ease breathing but it has been associated with minimal effectiveness. The patient denied any history of pain or headache.

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Medications: The patient currently uses Mucinex over-the-counter medication 1 tab orally on a daily basis.

Allergies: The patient denied any history of drug or food allergy. The patient reported history of seasonal allergies.

PMHx: The patient denied history of hospitalization, surgery, and blood transfusion. The immunization history of the client is up to date.

Social Hx: The patient is married with two children. The patient stopped smoking in 2012. He drinks alcohol on occasional basis. His highest level of education is university. He has a degree in business administration and works at a local supermarket as a manager. He reported to engage in active physical activity. He reported that the symptoms of the disease had affected his sleeping patterns significantly.

Family Hx: The parents of the patient are both alive. His father was diagnosed with diabetes in 2016 and has been on treatment. His mother was diagnosed with hypertension in 2020 and is on treatment. The patient is the second born in a family of three. His siblings are all alive and healthy.

General: The patient appeared well groomed for the occasion. He was oriented to time, place, and self.

He denied fevers, fatigue, or chills. The patient reported being tired due to lack of enough sleep secondary to the symptoms of the health problem.

HEENT: The patient denied headaches. The patient reported that his eyes are itchy and red. There were no changes in the vision. The tympanic membranes are intact, with absence of ear drainage of changes in hearing. The patient reported nasal congestion, itchy, with pale and boggy nasal mucosa. There was clear nasal drainage with slightly enlarged nasal turbinates. There was absence of tonsillitis. The throat was mildly erythematous.

Neck: The trachea was midline without any deviation or lymphadenopathy.

Skin: The patient denied skin rash, changes in skin color, and itching.

Cardiovascular: The patient denied chest pain, palpitations, discomfort, or edema.

Respiratory: The patient denied shortness of breath, cough or difficulty in breathing

Musculoskeletal: The patient denied joint or muscle pain.

Lymphatic: The client denied lymphadenopathy

Allergies: The client denied any known food or drug allergy. He reported seasonal allergies.

Objective

HEENT: The patient reports that his eyes are itchy. The eyes appear red. The tympanic membranes are intact with the absence of any drainage. The nasals are congested, with boggy, pale mucosa and inflamed nasal turbinates. There is the evidence of drainage of thin, clear secretion. There is mild erythema on the throat with absence of tonsillitis and bleeding.

Diagnostic Results

The skin test revealed a positive reaction to pollen. The results showed that the patient has allergic rhinitis. Allergic rhinitis is a condition of the upper respiratory system that arises from an individual exposure to an allergen. Patients experience symptoms that include sneezing, rhinorrhea, itchy nose and eyes, nasal congestion, and sore throat among others.

Diagnostic investigations are not recommended in allergic rhinitis since they do not have any cost benefits. Healthcare providers can utilize history taking and physical examination to diagnose patients with the condition. It is however important to perform tests such as skin tests to determine whether a patient has allergic rhinitis in people without history of allergic reactions.

Differential Diagnosis

Allergic Rhinitis: The first differential diagnosis for the patient is allergic rhinitis. As noted initially, allergic rhinitis is a respiratory condition that develops following an individual exposure to an allergen. The symptoms associated with allergic rhinitis include sneezing, nasal congestion, rhinorrhea, and itchy eyes. The symptoms developed due to IgE mediated reactions against the allergens (Okubo et al., 2020). Allergic rhinitis is the primary diagnosis for the patient due to the positive skin test.

Non-allergic rhinitis: Non-allergic rhinitis is the other possible condition affecting the client. Patients present with symptoms such as nasal congestion, rhinorrhea, sneezing, and itchy eyes among others. However, patients do not have history of allergic reactions to allergens (Zheng Ming et al., n.d.). This is the least diagnosis for the client in the case study because he has history of seasonal allergy.

Sinusitis: sinusitis refers to a condition where the paranasal sinuses are inflamed. Sinusitis is attributed to causes such as fungal, viral or bacterial infections and allergic reactions. Patients with sinusitis experience symptoms such as nasal congestion, headache, rhinorrhea, fever, and facial pain (Little et al., 2018). Sinusitis is however, the least possible condition due to the absence of signs and symptoms associated with infections.

Flu/Common cold: Common cold is the other potential diagnosis. Common cold is an acute viral infection affecting the upper respiratory system. It may involve sinuses, larynx or the pharynx. Patients experience symptoms such nasal drainage, malaise, fever, and headache among others. It is however the least likely due to the absence of signs and symptoms of infection (Sadeghirad et al., 2017).

Sore throat: Sore throat is the other potential diagnosis for the patient. Patients experience pain in the pharynx on swallowing. Sore throat is largely attributed to viral infections. The patient however is least suffering from sore throat because of the absence of signs and symptoms of infection (Mahalingam et al., 2020).

References

Little, R. E., Long, C. M., Loehrl, T. A., & Poetker, D. M. (2018). Odontogenic sinusitis: A review of the current literature. Laryngoscope Investigative Otolaryngology, 3(2), 110–114. https://doi.org/10.1002/lio2.147

Mahalingam, N. V., Abilasha, R., & Kavitha, S. (2020). Awareness of symptomatic differences COVID-19, sars, swine flu, common cold among dental students. International Journal of Research in Pharmaceutical Sciences, 11(Special Issue 1). https://doi.org/10.26452/ijrps.v11iSPL1.3431

Okubo, K., Kurono, Y., Ichimura, K., Enomoto, T., Okamoto, Y., Kawauchi, H., Suzaki, H., Fujieda, S., Masuyama, K., & Allergology, T. J. S. of. (2020). Japanese guidelines for allergic rhinitis 2020. Allergology International, 69(3), 331–345. https://doi.org/10.1016/j.alit.2020.04.001

Sadeghirad, B., Siemieniuk, R. A. C., Brignardello-Petersen, R., Papola, D., Lytvyn, L., Vandvik, P. O., Merglen, A., Guyatt, G. H., & Agoritsas, T. (2017). Corticosteroids for treatment of sore throat: Systematic review and meta-analysis of randomised trials. BMJ, 358, j3887. https://doi.org/10.1136/bmj.j3887

Zheng Ming, Wang Xiangdong, Ge Siqi, Gu Ying, Ding Xiu, Zhang Yuhuan, Ye Jingying, & Zhang Luo. (n.d.). Allergic and Non-Allergic Rhinitis Are Common in Obstructive Sleep Apnea but Not Associated With Disease Severity. Journal of Clinical Sleep Medicine, 13(08), 959–966. https://doi.org/10.5664/jcsm.6694

 SUBJECTIVE DATA:

Chief Complaint (CC): Number 4: “I have had a nasal congestion alongside itching that has occurred for the last five days . ”

History of Present Illness (HPI): The patient, M.S is 5o years of age and presented to the clinic complaining of having congested noses, sneezing, rhinorrhea, itching nose and ears, postnasal discharge, which symptoms have occurred for the last 5 days. Apparently, the patient employed the usage of Mucinex drug so as to help him with the breathing difficulty he was having. The patient reported that the medicine did not have any adverse effects on him but its effectiveness was minimal. The patient also did not report having any headache of pain.

Medications: The patient uses an over the counter medication called Mucinex, at 1 tab daily using the oral route.

Allergies: The patient did not accept having food or drug allergy. However, he reported the presence of seasonal allergies.

Past Medical History (PMH): He denied having been hospitalized or undergone blood transfusion before.

Past Surgical History (PSH): Has never undergone surgery.

Sexual/Reproductive History: He has never suffered from STIs, urinary incontinence, UTIs, or impotence.

Personal/Social History: The client has a wife and two children. He has not smoked since 2013. He is a social drinker. Has a university degree in BA and is employed as a supermarket manager in his locality. The disease interfered with his sleeping patterns.

Health Maintenance: He stated that he actively participates in physical activity.

Immunization History: Up-to-date immunization data.

Significant Family History: Both parents alive. The father is diabetic, which diagnosis occurred on 2017. The mother is hypertensive since 2019. The parents have three children and the patient is the last born of them. All the siblings are alive.

Review of Systems:

General: The patient was well-groomed. His orientation to self, time, and place was perfect. He did not accept having chills, fever or fatigue. He stated that the lack of sleep that he had caused him to be tired, which was secondary to the issue he was having.

HEENT: Denied the presence of headache. Reported itchy eyes. The eyes were also red. Vision remained the same. Intact tympanic membranes reported. Denied drainage of ears or hearing alterations. Reported that the nose was itchy. Presence of nasal congestion reported. Reported the presence of nasal mucosa that was boggy. The nasal discharge was clear but the turbinates were enlarged. Denied having tonsillitis. The throat showed mild erythema.

Respiratory: No significant issue as the trachea was in a midline position sans lymphadenopathy.

Cardiovascular/Peripheral Vascular: The patient did not have palpitations, chest pain, or edema, or discomfort.

Gastrointestinal: The patient denied vomiting, nausea, abdominal distention, as well as diarrhea.

Genitourinary: The patient did not report polyuria, oliguria, frequent urination, or dysuria.

Musculoskeletal: The patient did not report the presence of muscle/joint pain.

Neurological: The patient reported not having changes in gait, headache, body imbalance, as well as loss of sensations.

Psychiatric: The patient’s family did not have psychiatric illnesses.

Skin/hair/nails: The patient did not have any skin rash, alterations in skin color, or itching.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 109/78 P-80 Temp 37.5 RR-20 Weight 59 kg Height 6’2 BMI 24.8

General: The patient did not have any signs of distress. He was perfectly oriented.

HEENT: The patient’s eyes were red. His vision acuity was normal without eye drainage or pallor. Intact tympanic membranes present. Hearing did not have changes. Boggy and pale nasal mucosa present. Nasal turbinates were slightly elongated but the nasal drainage was clear. Tonsilities not present. Mildly erythematous throat seen.

Neck: Carotids did not have bruit, thyromegally or jvd

Chest/Lungs: Normoactive lung sounds. Respiratory muscles inactive during breathing.

Heart/Peripheral Vascular: RRR did not have murmur, gallop or rub

Abdomen: Absence of abdominal distention. Presence of normal bowel movements. Organomegally absent.

Genital/Rectal: Declined by the patient.

Musculoskeletal: Symmetry in muscle development without noticeable abnormal fractures or gait.

Neurological: Absence of loss of sensation, muscle paralysis, as well as movements

Skin: No clubbing, cyanosis, edema; no palpable nodes

Diagnostic results: Positive skin test to pollen

ASSESSMENT:

Differential Diagnosis

Allergic Rhinitis: Allergic rhinitis appears to as the first differential diagnosis for the chosen patient. The presence of an allergen may result to the manifestation of allergic rhinitis. The symptomatology of the condition is inclusive of nasal congestion, rhinorrhea, itchy eyes, and sneezing (Bousque et al., 2020). Regarding the patient, these symptoms occurred as a result of the IgE mediated reactions versus the seasonal allergens affecting the patient. Its primary diagnosis was based on the positive skin test that was conducted.

Non-allergic rhinitis: The patient could also be suffering from non-allergic rhinitis. The patients having this condition also share similarities in the symptomatology with the primary diagnosis.

(Zheng Ming et al., n.d.). This forms the least possible options due to the presence of seasonal allergic reaction history.

Sinusitis: Sinusitis connotes a condition that is characterized by inflammation of the paranasal sinuses. The condition is caused by various factors including allergic reactions, bacterial or viral infections, and fungal. The symptoms of sinusitis include headache, facial pain, nasal congestion, fever, and rhinorrhea (Psillas et al., 2021). However, sinusitis is the slightest condition because it lacks signs and symptoms linked to infections.

 Flu/Common Cold: The other possible diagnosis is common cold which is an acute viral respiratory infection that affects the upper part of the respiratory system. It impacts sinuses, and the pharynx. Flu symptoms include nasal drainage, malaise, headache and fever (Thomas & Bomar, 2021). However, there are no signs and symptoms in this case.

Sore Throat: Sore throat is also a possible diagnosis for the patient. Sore throat entails pain when swallowing in the pharynx. It is main a viral infection (Taymaz et al., 2021). However, the possibility of sore throat is the least in this case since the patient does not present any signs and symptoms.

 PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

References

Bousquet, J., Schünemann, H. J., Togias, A., Bachert, C., Erhola, M., Hellings, P. W., … & Its Impact on Asthma Working Group. (2020). Next-generation Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence. Journal of Allergy and Clinical Immunology, 145(1), 70-80. https://doi.org/10.1016/j.jaci.2019.06.049

Psillas, G., Papaioannou, D., Petsali, S., Dimas, G. G., & Constantinidis, J. (2021). Odontogenic maxillary sinusitis: A comprehensive review. Journal of Dental Sciences, 16(1), 474-481. https://doi.org/10.1016/j.jds.2020.08.001

Scadding, G. K., Kariyawasam, H. H., Scadding, G., Mirakian, R., Buckley, R. J., Dixon, T., … & Clark, A. T. (2017). BSACI guideline for the diagnosis and management of allergic and non‐allergic rhinitis (Revised Edition 2017; 2007). Clinical & Experimental Allergy, 47(7), 856-889. https://doi.org/10.1111/cea.12953

Taymaz, T., Ergönül, Ö., Kebapcı, A., & Okyay, R. (2018). Significance of the detection of

influenza and other respiratory viruses for antibiotic stewardship: lessons from the post-pandemic period. International Journal of Infectious Diseases, 77, 53-56. DOI:https://doi.org/10.1016/j.ijid.2018.10.003

Thomas, M. & Bomar, P. A. (2021). Upper Respiratory Tract Infection. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK532961/

SUBJECTIVE DATA:

 Chief Complaint (CC): “Stretch marks.” (Image 2)

 History of Present Illness (HPI): W.T. is a 26-year-old AA female presenting to the dermatologic clinic with complaints of stretch marks. She is concerned about her appearance and wishes to know if there is any cream she can use to reduce the appearance of stretch marks. She is pregnant, and the gestation by date (GBD) is 32 weeks. The stretch marks began appearing when she was about 22 weeks pregnant, and they have increased in number and size as the pregnancy progressed. She reports having used cocoa butter, shea butter lotions, and various stretch marks creams, but they have been ineffective.

medications: Iron and Folic acid Supplements

 Allergies: Allergic to Penicillin- causes a rash.

 Past Medical History (PMH): No chronic illnesses.

Past Surgical History (PSH): Tonsillectomy at 6 years.

Sexual/Reproductive History: Para 0+0, Gravida-1; No history of STIs or gynecological disorders. Had UTI at 16 weeks GBD but was successfully treated with Nitrofurantoin. She was previously on IUD.

 Personal/Social History: W.T. is married and lives with her husband in Baltimore, MD. She has a Diploma in Secretarial studies and works as a corporate secretary. Her hobbies are baking and traveling. She reports having about six small meals and about 3L of water daily. She used to smoke ½ PPD and drink 2-3 glasses of vodka on her off days before getting pregnant. She denies currently taking alcohol, smoking, or using any drug substances. The patient states that her husband and elder sister are her support system.

Health Maintenance: The patient reports attending antenatal checkups and adheres to the daily Iron and Folic Acid supplements.

 Immunization History: Her immunization status is up to date. She had a TT2 booster in the last antenatal visit. The last Flu shot was 8 months ago.

Significant Family History: The maternal grandmother has Rheumatoid arthritis and HTN. The father was recently diagnosed with diabetes. Her siblings are alive and well.

Review of Systems:

General: Denies fever, generalized weakness, or chills.

HEENT: Denies eye redness, excessive tearing, blurred vision, nasal secretions, or swallowing difficulties.  

Respiratory: Denies breathing difficulties, wheezing, or coughing.

Cardiovascular/Peripheral Vascular: Denies edema, chest tightness, palpitations, or exertional dyspnea.

Gastrointestinal: Reports occasional nausea and vomiting. Denies abdominal pain, heartburn, diarrhea, or constipation.  

Genitourinary: Reports urine frequency and increased PV discharge. Denies foul-smelling discharge, lower abdominal pain, or urinary urgency.

Musculoskeletal: Denies back pain, joint stiffness, or pain.

Neurological: Negative for headaches, dizziness, or muscle weakness.

Psychiatric: Negative for psychotic, mood, or anxiety symptoms.

Skin/hair/nails: Reports stretch marks. Denies itching, burning sensation, rashes, bruising, or brittle nails

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP-122/78; HR-80; RR-16; Temp-98.4; HT-5’4; WT- 154 lbs.

General: AA female client in no distress. She is alert and oriented x3.

HEENT: Head is symmetrical; Eyes: Sclera is white; Conjunctiva is pink; PERRLA; Ears: Intact and shiny TMs

Neck: Symmetrical and Supple. Thyroid gland normal on palpation.

Chest/Lungs: Uniform chest expansion. Smooth respirations; Lungs clear on auscultation.

Heart/Peripheral Vascular: No edema or neck vein distension. Regular heart rate and rhythm; S1 and S2 present; No murmurs.

Abdomen: Gravid abdomen; The abdominal skin is stretched with marked striae. Linea nigra present; Normoactive BS; FHR-142b/min; Gravid mass on palpation; No tenderness on palpation; No organomegaly.

Genital/Rectal: Normal female genitalia. Intact anal sphincter.

Musculoskeletal: Active ROM; No joint deformities.

Neurological: Clear speech; CNs are intact; Muscle strength- 5/5; Upright posture; Steady gait.

Skin: Flat dark streaks on the abdomen. The dark streaks are raised, 1-10 mm wide, and the length varies at 1-5 cm. A dark vertical line runs from the diaphragm to the pubic area.

 Diagnostic results: No tests were ordered.

ASSESSMENT:

Striae gravidarum: Striae gravidarum are stretch marks that appear during pregnancy. They are caused by thin tears in the dermal collagen. They appear as flat red or hypopigmented stripes that become raised, longer, wider, and violet-red (Abbas et al., 2018). The patient has dark flat streaks on the abdomen that first occurred during pregnancy, which align with Striae gravidarum.

Anetoderma: It is characterized by flaccid, well-circumscribed areas of slack skin. Sac-like protrusions can sometimes be observed in some lesions. It is attributed to the loss of elastic fibers within the dermis (Genta et al., 2020). Histopathology is necessary to confirm or rule out Anetoderma to determine if elastic tissue is lost in the dermis.

Lichen sclerosus: This is a rare autoimmune skin condition characterized by skin atrophy and hypopigmentation. It commonly affects genital skin. It typically begins as a sharply demarcated erythema that progresses into thin, hypopigmented, ivory-white, and sclerotic plaques. The plaques are surrounded by a purple, red, or violet border (Singh & Ghatage, 2020). The hypopigmented streaks make this a differential diagnosis. However, the patient has no plaques, and the streaks are not in the genital area ruling Lichen sclerosus as the primary diagnosis.

Elastotic striae: This is a rare skin condition that manifests as asymptomatic atrophic yellow lines on the thighs, mid or lower back, arms, or breasts. It manifests clinically with asymptomatic, numerous, yellowish, elevated, irregularly indurated, striae-like lines or bands spread horizontally across the lower and middle part of the posterior trunk (Palaniappan et al., 2023). The patient has raised irregular streaks, but they are not in the posterior trunk, making this an unlikely primary diagnosis.

Scarring: Scars present as raised, firm nodules or plaques, usually at sites of previous trauma (Barone et al., 2021). However, the patient has no history of abdominal trauma, which rules out scarring as the cause of the hypopigmented streaks.

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Abbas, A. M., Kamel, F. M., & Salman, S. A. (2018). Clinical significance and treatment of striae gravidarum during pregnancy: a review article. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 8(1), 368. doi:10.18203/2320-1770.ijrcog20185454 

Barone, N., Safran, T., Vorstenbosch, J., Davison, P. G., Cugno, S., & Murphy, A. M. (2021). Current Advances in Hypertrophic Scar and Keloid Management. Seminars in plastic surgery, 35(3), 145–152. https://doi.org/10.1055/s-0041-1731461 Lokhande, A. J., & Mysore, V. (2019). Striae Distensae Treatment Review and Update. Indian dermatology online journal, 10(4), 380–395. https://doi.org/10.4103/idoj.IDOJ_336_18

Genta, M. P., Abreu, M. A. M. M., & Nai, G. A. (2020). Anetoderma: an alert for antiphospholipid antibody syndrome. Anais brasileiros de dermatologia, 95(1), 123–125. https://doi.org/10.1016/j.abd.2019.04.010

Palaniappan, V., Selvaarasan, J., Murthy, A. B., & Karthikeyan, K. (2023). Linear focal elastosis. Clinical and Experimental Dermatology, 48(3), 175-180. https://doi.org/10.1093/ced/llac071

Singh, N., & Ghatage, P. (2020). Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review. Obstetrics and gynecology international, 2020, 7480754. https://doi.org/10.1155/2020/7480754

Lab Assignment: Differential Diagnosis for Skin Conditions 

Patient Initials: S.P  Age: 30 years           Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “Stretch marks.” (Image 2)

History of Present Illness (HPI): S.P. is a 30-year-old AA woman who presented to the dermatology clinic inquiring if there is a therapeutic remedy for stretch marks on the abdomen. She is a Para 1+0 Gravida 2, and gestation is at 34 weeks. The stretch marks started appearing at around 26 weeks gestation and have increased in number throughout the gestation.

She states that she had some abdominal stretch marks in the previous pregnancy, but they did not bother her since they were not many and were faint. However, during this pregnancy, the stretch marks are more prominent and have spread on the whole abdomen. She is concerned that the stretch marks may never fade and will be permanent throughout her life. The client states that this will affect her body image since she cannot wear revealing clothes anymore.

Besides, she has a massive social media following, whom she is worried will harshly judge her body due to the stretch marks. She reports having used stretch marks lotions, but they have been ineffective. She has also used Bio-oil, which she was told helps to fade the stretch marks, but they have become more prominent.

Medications:

Iron and Folic acids supplements.

Allergies:

Allergic to Sulphur- causes a rash.

Past Medical History (PMH):

No history of chronic conditions.

Past Surgical History (PSH): No surgical history

Sexual/Reproductive History:

Para 1+0; Gravida 2. History GBD- 34 weeks

Personal/Social History:

The patient is married and lives with her husband and one child, 3 years old. She has a history of occasional alcohol intake but has not been taking alcohol during pregnancy. She denies tobacco smoking or other substance use.

Immunization History:

Influenza shot- August 2022

Tdap- 3^rd booster at 20 weeks

Significant Family History:

The maternal grandmother had HTN and died from a stroke at 87 years. The paternal grandmother died from cervical cancer at 74 years. The mother has HTN, but the father and siblings are alive and well.

Lifestyle:

S.P. is a digital content creator, and her work involves marketing brands and products on social media. She lives in a middle-income neighborhood in Seattle, WA. She has private health insurance coverage. Her hobbies are traveling and photography. The client reports taking 4-5 meals daily during the pregnancy and sleeping 7-8 hours.

Review of Systems:

General: Reports weight gain and increased fatigue during pregnancy. Denies fever, chills, or malaise.

HEENT: Denies headache, vision changes, eye pain, ear pain, ear discharge, sneezing, rhinorrhea, sore throat, or pain when swallowing.

Neck: Denies stiffness.

Breasts: Reports breast tenderness and darkening of areola. Denies nipple discharge, breast lumps, or masses.

Respiratory: Denies chest pain, cough, or SOB.

CV: Denies dyspnea, palpitations, or chest pain.

GI: Positive for occasional nausea and vomiting. Denies epigastric/ abdominal pain, bowel changes, or tarry stools.

GU: Reports increased vaginal secretion and urinary frequency. Denies dysuria, vaginal irritation, or urine color changes.

MS: Positive for occasional back pain. Denies joint pain or stiffness.

Psych: Denies psychiatric symptoms.

Neuro: Denies headache, dizziness, muscle weakness, or tingling sensations.

Integument/Heme/Lymph: Reports stretch marks and abdominal hyperpigmentation. Denies skin irritation, bruises, or lesions.

Endocrine: Denies excessive thirst, hunger, or urine production

Allergic/Immunologic: Denies allergic infections.

 OBJECTIVE DATA

 Physical Exam:

Vital signs: B/P 124/80, HR-92; Temp- 98.4; RR-16;

Wt: 148 lbs; Ht: 5’5.

General: The patient is alert and in no distress. She is neat and dressed appropriately for the event. She maintains adequate eye contact and speaks at normal volume and rate.

HEENT: The head is symmetrical. Eyes: White sclera; Pink conjunctiva; PERRLA. Ears: Tympanic membranes are intact and shiny. Nose: Mucosal membranes are pink and wet. Throat: Non-inflamed Tonsillar glands.

Neck: Full ROM Thyroid gland is normal.

Chest/Lungs: Smooth and even respirations; Lungs are clear on auscultation; S1 and S2 present. No murmurs or S gallops are present. 

ABD: The abdomen is round and gravid. Moves up and down with respiration. A hyperpigmented vertical line runs midline from below the diaphragm to the pubic area. Hyperpigmented linear lesions on both sides of the stomach are about 5 mm wide and 4 cm long. The lesions are slightly above the skin surface and run perpendicularly to the skin tension.

 Bowel sounds are Normoactive; No tenderness on palpation or muscle guarding.

Genital/Rectal: Normal female genitalia. The anal sphincter is intact  

Musculoskeletal: Symmetrical joints and muscles with no swelling, erythema, or deformity. Active range of motion of all joints.

Neuro: Normal gait and posture and good balance. Muscle strength- 5/5. CN II – XII are intact

Skin: Slightly raised hyperpigmented lesions on the abdomen. The lesions are irregularly shaped, about 5 mm wide and 4 cm long.

Lymph Nodes: Non-palpable.

Diagnostics/Lab Tests and Results:  No tests were requested.

 Assessment:

 Differential Diagnosis (DDx):

Striae gravidarum: Striae gravidarum refer to linear atrophic scars that occur during pregnancy. This is the most common integumentary change during pregnancy. They are characterized by linear bands that are at first erythematous to violaceous and slowly fade to become skin-colored or hypopigmented atrophic lines, usually thin or wide (Yu et al., 2022).

They occur on the breasts, abdomen, buttocks, hips, and thighs and often develop after 24 weeks gestation. Striae gravidarum is the presumptive diagnosis based on positive findings of hyperpigmented linear lesions on both sides of the stomach that started appearing from 26 weeks gestation.

Linear Focal Elastosis: Linear focal elastosis is an acquired, dermis elastic tissue condition that presents with asymptomatic, yellowish or red, horizontal, indurated, palpable, atrophic or hypertrophic, striae-like linear plaques (Palaniappan et al., 2022). The plaques are spread symmetrically across the mid and lower back. This is a differential diagnosis owing to the palpable linear plaques present in the patient. However, linear focal elastosis develops on the back, making it an unlikely primary diagnosis for this case.

Lichen Sclerosus: Lichen sclerosus is a chronic inflammatory dermatosis. It is characterized by flat, atrophic, yellowish-white plaques with a red, purple, or violet border. The plaques are associated with pruritus and pain that causes scarring and adhesion (Tran et al., 2019). This is a differential based on the presence of flat plaques. Nonetheless, the patient’s plaques are dark rather than yellowish-white and have no border, ruling out Lichen sclerosus as the primary diagnosis.

PLAN: [This section is not required for the assignments in this course but will be required for future courses.]

References

Palaniappan, V., Selvaarasan, J., Murthy, A. B., & Karthikeyan, K. (2022). Linear focal elastosis. Clinical and Experimental Dermatology. https://doi.org/10.1093/ced/llac071

Tran, D. A., Tan, X., Macri, C. J., Goldstein, A. T., & Fu, S. W. (2019). Lichen Sclerosus: An autoimmunopathogenic and genomic enigma with emerging genetic and immune targets. International journal of biological sciences, 15(7), 1429–1439. https://doi.org/10.7150/ijbs.34613

Yu, Y., Wu, H., Yin, H., & Lu, Q. (2022). Striae gravidarum and different modalities of therapy: a review and update. Journal of Dermatological Treatment, 33(3), 1243–1251. https://doi.org/10.1080/09546634.2020.1825614

Diversity and Health Assessments

We need to be culturally competent as healthcare providers in order to adapt our communication and provide care that best meets the needs of our patients. To be culturally competent, healthcare professionals must be conscious of their own biases and beliefs and avoid letting them obstruct their ability to comprehend the patients’ unique cultural values (Ball et al., 2019, pg. 22).

Healthcare providers who do not strive to provide culturally competent care put patients at risk for poorer health outcomes and dissatisfied care (Swihart et al., 2021). Following the RESPECT Model can aid healthcare practitioners in continuing to communicate with patients in an efficient and patient-centered manner (Ball et al., 2019, p. 31).  

Mrs. Paloma Hernandez is a 26-year-old Spanish-speaking patient who has presented to the clinic for the last two days complaining of worsening abdominal pain and dyspepsia. Mrs. Hernandez’s husband could not accompany her to the visit because he was working, but she brought her bilingual daughter, who acted as a translator during the first visit. This paper will discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with Mrs. Hernandez.

Omeprazole was prescribed for Mrs. Hernandez’s peptic ulcer disease, with other over-the-counter drugs to treat her stomach pain. Mrs. Hernandez stated she was using ibuprofen for her abdominal pain because that helps her when she experiences period cramps or a headache. She states she has taken the omeprazole twice daily, typically after a meal, because that’s when her abdominal pain worsens.

Upon further investigation, it appears that crucial information and teaching were lost because her eight-year-old daughter was used as a translator during the last visit. A certified medical interpreter will be employed for this appointment. A linguistic barrier that prevents good communication raises the possibility of misdiagnosis, misinterpretation of the recommended course of treatment, and reduced drug compliance (Center for Medicare Advocacy, n.d.).

Mrs. Hernandez was raised and received her high school certificate in Mexico, where she was born. She married and had a daughter soon after graduating, so she chose not to attend college. She moved to the United States from Mexico three years ago with her kid and husband.

Since moving to the United States, she has made friends with another Hispanic family in the apartment building below them. Her daughter is eight years old and attending school. Mrs. Hernandez is unemployed, and her husband works odd jobs until he can secure a more permanent job. Mrs. Hernandez is uninsured and lives in a low-income household.

Hispanic Americans are less likely than other Americans to obtain health insurance and get preventative care (Funk & Lopez, 2022). Compared to their wealthier counterparts, those with low incomes or low levels of education had much higher rates of illness and death (Ball et al., 2019, p. 24).

Compared to Asian/Pacific Islanders and non-Hispanic whites, the percentage of Hispanics without insurance is significantly greater (Ball et al., 2019, p. 24). To enhance the patient’s health, a practitioner must recognize and address the health disparities that exist between various racial and ethnic groups due to socioeconomic injustices.

Being a Roman Catholic, Mrs. Hernandez places a high value on religion. She has been asking Our Lady of Guadalupe for assistance in getting rid of her stomach pains. She claims the reason she is experiencing stomach discomfort is because God is punishing her. Respecting and being culturally sensitive to Mrs. Hernandez’s religious beliefs is vital to building trust and a solid provider-patient relationship.

To create a suitable diet plan while receiving treatment for peptic ulcer disease, understanding Mrs. Hernandez’s dietary habits and nutritional practices is essential. According to Mrs. Hernandez, the discomfort is greatest after eating and at night. Mrs. Hernandez has coffee with her morning meal. She eats a small beef sandwich for lunch while her daughter is at school.

She frequently buys fast food for the family’s dinner since it is affordable and convenient. After dinner, she stops by her neighbors’ apartment below for a sobremesa, where they talk about their day over coffee and an alcoholic beverage. A sobremesa’s cultural significance in Mrs. Hernandez’s life must be understood. She can participate in the sobremesa while consuming drinks that are good for her ulcer by recommending she switch to a nonalcoholic beverage that doesn’t include caffeine rather than discourage her from going to the sobremesa completely. 

To be effective, treatment must be tailored to the patient’s cultural values (Young & Guo, 2016). Understanding Mrs. Hernandez’s distinctive cultural values foster patient trust and give important information for creating a treatment plan that considers her views. By using an appropriate medical interpreter, I could close the language barrier gap, gather more detailed information about her culture, and build a trusting relationship.

Together, we created a reasonable diet and treatment regimen for her peptic ulcers. She was instructed on the value of refraining from using any NSAIDs and when she should take her omeprazole. Additionally, she received a handout with individualized and appropriate diet choices and treatment plan, so she and her husband could reference them.  

The targeted questions I would ask the patient to build her health history and to assess her health risks are:

1. Are there any cultural beliefs or customs you would like to keep related to treating your abdominal pain?
2. Are there any special herbs/foods/treatments you have found helpful?
3. How does your family think your abdominal pain should be treated?
4. What do you think is causing your abdominal pain? How have you treated the abdominal pain so far?
5. What food/drinks have you consumed in the last 48 hours? What times?
6. How would you like your family to be involved in your care?
7. What is your ethnicity?
8. What is the highest level of schooling that you have finished?
9. Do you feel physically and emotionally safe where you live?
10. Have you worried about affording food, utilities, or medicine?
11. Have you ever been afraid of your partner?

These focused inquiries offer a thorough understanding of Mrs. Hernandez’s cultural background, dietary habits, and socioeconomic level. Significant risk factors for the health inequalities that Hispanics encounter are obesity and the comorbidities it creates (type 2 diabetes, dyslipidemia, and nonalcoholic fatty liver disease) (Fernandez, 2021). Poor diets, insufficient exercise, and smoking are typically health-related risk factors in those with lower socioeconomic status (American Academy of Family Physicians, 2018).

By using these interview questions to build a health history, I may gather culturally pertinent information, create a treatment plan that is sensitive to the patient’s culture, and identify any particular health concerns the patient may have.

The patient I was assigned is a 33-year-old transgender male currently taking Biktarvy and 100mg of testosterone. He is HIV positive, unemployed, suffers from depression, and is moving back home to live with his family. He smokes two packs of cigarettes per day and marijuana on the weekends. He has not seen a doctor since he transitioned and is not providing a past medical history. There are many cultural factors to consider when caring for this patient, including his scant health care, sexual identity, socioeconomic status, and lifestyle. 

Trust is the foundation of the patient-provider relationship, and to gain a patient’s trust, you must be culturally competent. This entails looking at the patient as a unique individual without applying stereotypes and being aware of one’s knowledge and cultural perspective limitations. The first question I would ask the patient would be 1) What are your pronouns, and do you have another name besides your birth name that you would like me to call you?

This question will help build trust and show that I respect the patient’s life choices. The RESPECT model is a valuable tool for practitioners to be culturally competent. RESPECT stands for rapport, empathy, support, partnership, explanations, and trust. The RESPECT model allows for effective cross-cultural communication and enables a positive patient-provider relationship (Ball et al., 2023).

The patient recently transitioned to male publicly a year ago and is battling HIV. Depression is common among transgender individuals living with HIV. One study found that transgender women with HIV were at a higher risk for developing depression and were found to be less compliant with their HIV suppression medication (Poteat, 2020).

That being said, my second question would be 2) Have you been feeling depressed? Not only has the patient recently changed his sexual identity, but he is also unemployed and moving back in with his family. Depending on the patient’s response, I would incorporate mental health into the plan of care. 

 The third question would be: 3) Are you good about taking your Biktarvy as directed? It is essential to ask the patient if they are compliant with their medications before deciding on a new course of treatment. The patients declining health could be from non-compliance with the Biktarvy. 

The fourth question I would ask would be 4) How do you feel about the number of cigarettes you smoke, and are you aware of its effects on your health? One study found that individuals with HIV and depression were likelier to smoke cigarettes to increase their mood and manage pain habitually (Stanton et al., 2021).

Allowing the patient to discuss their lifestyle choices rather than telling them why they are harmful can promote a non-judgmental open dialog between the patient and the provider. Depending on the patient’s response, resources such as HIV support groups and smoking cessation tools can be provided. 

The fifth question that I would ask would be 5) How do you feel about testosterone therapy? Because the patient is receiving testosterone via the internet, it is important to question the patient on any unusual side effects. Depending on the patient’s response, I would offer to write a new prescription to make any adjustments and ensure patient safety. 

References 

Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s Guide to physical examination. Elsevier.

Poteat, T. C., Celentano, D. D., Mayer, K. H., Beyrer, C., Mimiaga, M. J., Friedman, R. K., Srithanaviboonchai, K., & Safren, S. A. (2020). Depression, sexual behavior, and HIV treatment outcomes among transgender women, cisgender women and men who have sex with men living with HIV in Brazil and Thailand: a short report. AIDS Care, 32(3), 310–315. https://doi.org/10.1080/09540121.2019.1668526Links to an external site.

Stanton, A. M., Lee, J. S., Wirtz, M. R., Andersen, L. S., Joska, J., Safren, S. A., van Zyl-Smit, R., & O’Cleirigh, C. (2021). Tobacco Use and Health-Related Quality of Life Among Individuals with Depression Who Are Receiving Treatment for HIV in Cape Town, South Africa. International Journal of Behavioral Medicine, 28(4), 417–430. https://doi.org/10.1007/s12529-020-09951-z

Rubric

NURS_6512_Week_4_Assignment_1_Rubric

NURS_6512_Week_4_Assignment_1_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning Outcome Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: ·  Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). ·   Use clinical terminologies to explain the physical characteristics featured in the graphic.	35 to >29.0 pts Excellent The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies. 29 to >23.0 pts Good The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies. 23 to >17.0 pts Fair The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies. 17 to >0 pts Poor The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.	35 pts
This criterion is linked to a Learning Outcome ·   Formulate a different diagnosis of three to five possible considerations for the skin graphic.    ·   Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.	50 to >44.0 pts Excellent The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature. 44 to >38.0 pts Good The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature. 38 to >32.0 pts Fair The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature. 32 to >0 pts Poor The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.	50 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	5 to >4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.0 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 2 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.	5 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) APA format errors. 3 to >2.0 pts Fair Contains several (3 or 4) APA format errors. 2 to >0 pts Poor Contains many (≥ 5) APA format errors.	5 pts
Total Points: 100

LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

TO PREPARE

• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
• Consider which of the conditions is most likely to be the correct diagnosis, and why.
• Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
• Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
• Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

THE LAB ASSIGNMENT

• Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
• Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of 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.

BY DAY 7 OF WEEK 4

Submit your Lab Assignment. 

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area. 

1. To submit your completed assignment, save your Assignment as WK4Assgn1+last name+first initial.
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

NURS_6512_Week_4_Assignment_1_Rubric

NURS_6512_Week_4_Assignment_1_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeUsing the SOAP (Subjective, Objective, Assessment, and Plan) note format: ·  Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). ·   Use clinical terminologies to explain the physical characteristics featured in the graphic.	35 to >29.0 pts Excellent The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies. 29 to >23.0 pts Good The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies. 23 to >17.0 pts Fair The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies. 17 to >0 pts Poor The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.	35 pts
This criterion is linked to a Learning Outcome·   Formulate a different diagnosis of three to five possible considerations for the skin graphic.    ·   Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.	50 to >44.0 pts Excellent The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature. 44 to >38.0 pts Good The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature. 38 to >32.0 pts Fair The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature. 32 to >0 pts Poor The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.	50 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	5 to >4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.0 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 2 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.	5 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) APA format errors. 3 to >2.0 pts Fair Contains several (3 or 4) APA format errors. 2 to >0 pts Poor Contains many (≥ 5) APA format errors.	5 pts
Total Points: 100

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