Soap Note: Differential Diagnosis
ASSESSMENT
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Differential Diagnosis
Mucosal candidiasis: This is fungal infection of the oral cavity caused by fungus albicans. This infection present as a red or white lesion in the different parts of the mouth. An overgrowth of this infection may result to obstruction of the larynx in chronic cases of the disease. There is pain in both acute and chronic states of the disease. Weakened immune system due to malignancy predispose one to oral thrush. Smoking and alcohol disturbs the oral normal flora ((Epstein, & Saunders, 2016).
Actinic keratosis: These are oral lesion usually induced UV light after long term exposure to the sun.
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Erythroplakia: these are red lesions found the oral cavity usually in the floor. They are the pre-malignant lesions which present with either white, red or both colors in the oral cavity. Without comprehensive clinical management, these lesions may grow in size and histology to become a cancerous tissues in the mouth(Epstein, & Saunders, 2016).Staging of these lesions is essential to avoid misdiagnosis.
Final diagnosis
The final diagnosis for the above patient is oral cancer.
Evidence to support the diagnosis
The qualifying characteristics of oral cancer in this patient is the presence of large mass in the oral cavity and abnormal weight loss(Regezi, Sciubba, & Jordan, 2016)..
PLAN
Treatment of oral cancer involves several approaches primarily pharmacological and non-pharmacology.
PHARMACOLOGIC TREATMENT
Chemotherapy is the primary treatment option of treating cancer depending on the stage of the disease…
NON-PHARMACOLOGIC TREATMENT
This include the surgical, radiation and nutritional therapy. Oral cancerous tumors are removed through surgery..
EDUCATION
Providing health messages to the patient is very important to modify the nutritional behaviors and general lifestyles…
FOLLOW-UPS/ REFERRALS
Follow ups are necessary to ensure that patient is adhering to prescribed therapy at home.
REFLECTION NOTES.
Patients with such presentation require a holistic approach to their lifestyle and behaviors. In an event of similar evaluation of such a case, asking the patient his nutritional status is important. The components of food intake, any problems associated with intake and the attempted solutions to correct the situation should be included in the patient information. This practicum experience provide very significant opportunities for learners to transfer the literature knowledge into practice and be able to fill the gaps that exist between research and practice.
References
Brunner, L. and Suddarth, D. (2010). Text Book of Medical Surgical Nursing. 12th Edition. J.B. Lippincott Williams & Wilkins, Library of Congress Cataloging-in-Publication Data
Beitz, J. M. (2014). 1. Abstract 2. Introduction and epidemiology 3. Pathophysiology 4. Risk factors/diagnosis 5. Clinical Presentation 5.1. Motor. Front Biosci, 6, 65-74
Epstein, J. B., & Saunders, D. P. (2016). Managing Oral Mucositis Cancer Therapy.
Regezi, J. A., Sciubba, J. J., & Jordan, R. C. (2016). Oral pathology: clinical pathologic correlations. Elsevier Health Sciences.
