Week 4 Soap Note Sample Paper

Week 4 Soap Note Sample Paper

NURS 6512 Week 4 Soap Note – Lab Assignment: Differential Diagnosis for Skin Conditions

SOAP Note

Student’s Name:

Institutional Affiliation:

Comprehensive SOAP NOTE

Patient Initials: ___N/A____              Age: ___N/A____                              Gender: ___N/A____

SUBJECTIVE DATA:

Chief Complaint (CC): #3

History of Present Illness (HPI):   A Caucasian male whose age is unknown presents with non-scaly annual papules distributed along his nape. The papules have undiluted borders and appear reddish in color.

Medications:  No medical history provided.

Allergies: No known allergies.

Past Medical History (PMH): Past medical history not provided.

Past Surgical History (PSH): No surgical history provided.

Sexual/Reproductive History: Not provided. Ask about his sexuality, the number of sexual partners, pregnancy, and whether the patient has a history of sexually transmitted infections.

Personal/Social History: Not provided. Enquire on his hobbies, place of work, traveling history, and whether he smokes or use any recreational drugs.

Immunization History: Not provided. Collect the patient immunization details.

Significant Family History: Not provided. Inquire if there are family members with any skin complications. Inquire about other family’s medical conditions that might contribute to skin infections.

Review of Systems:

General:  Not reported. Inquire for symptoms of fatigue, fever, sweating, or any significant weight changes.

HEENT: Not reported. Inquire about any vision or hearing changes, any chewing or swallowing difficulty, and any nasal complications.

Neck: Red lesions distributed on the back of the neck.

Breasts:  No reported complications. Ask if the patient has a history of lesions, masses, or rashes.

Respiratory:  No reported complications.

CV: No reported complications.

GI: No reported complications.

GU:  No reported complications. Ask if the patient has had any lesions or rashes on his genital areas.

MS: No reported complications.

Psych: No reported complications.

Neuro: No reported complications.

Integument/Heme/Lymph:  Red lesions at the back of the neck.  Ask if the lesions are present in other parts of the body.

Endocrine: No endocrine symptoms reported.

Allergic/Immunologic: No known allergies.

OBJECTIVE DATA

Physical Exam:

Check for the patient’s vital signs. Vital signs include blood pressure, temperature, heart rate, and body mass index.

General: Check for the patient’s appearance and signs of fatigue and discomfort.

HEENT: Investigate the eyes, ears, and nose for any abnormalities.

Neck: Non-scaly annual papules at the back of the neck. Palpate the lesions to determine the texture and warmness.

Chest/Lungs: Check the chest for the presence or rashes or lesions.

Heart/Peripheral Vascular: N/A

ABD:  Check the abdomen for the presence of rashes or lesions

Genital/Rectal:  Investigate the genitalia for the presence of rashes.

Musculoskeletal: N/A

Neuro: N/A

Skin/Lymph Nodes:  Non-scaly annual lesions at the back of the neck. Check whether there are further lesions on other skin regions.

ASSESSMENT:

Diagnostics:

Lab:

Various laboratory procedures can be used to guide the diagnosis. The following are some of the recommended procedures.

Dermoscopy. The procedure uses a skin surface microscope known as a dermatoscope to magnify the lesion (Colyar, 2015). The process aims at providing a more detailed investigation of the lesion to make a diagnosis and determine the skin lesions that require a biopsy (Colyar, 2015).

Diascopy. The process involves pressing a glass or plastic slide on the lesion and noting any color changes (Colyar, 2015). The procedure determines whether determining the type of lesions. For example, whether it is hemorrhagic or not (Colyar, 2015).

Punch Biopsy.  This involves collecting a cylindrically shaped tissue sample (Colyar, 2015). The medical practitioner first cleans the skin and administers local anesthesia. The practitioner then stretches the skin and rotates a biopsy instrument while exerting downward pressure (Colyar, 2015). The procedure obtains a specimen that is then sent for culture to identify the bacteria or virus, causing the condition (Colyar, 2015).

Differential Diagnosis (DDx):

Tinea corporis. This is a skin condition that causes red, itchy, and circular rashes on the skin (Halder & Nootheti, 2014). Symptoms include itchy ring-shaped lesions that appear commonly on the arms and legs (Halder & Nootheti, 2014). However, the rashes may also appear on any part of the body. The rings may also overlap and appear red in color (Halder & Nootheti, 2014). Common causes of tinea corporis are skin to skin contact with an infected person or an animal (Halder & Nootheti, 2014).

Pityriasis rosea. This is a form of skin rash that starts as an oval spot on the back or the chest that then spreads to the other body parts (Halder & Nootheti, 2014). It commonly affects individuals between ages 10-35 and may clear on its own after around ten weeks (Halder & Nootheti, 2014). Symptoms of the condition are large and slightly raised red patches, fatigue, fever, and itching (Halder & Nootheti, 2014). The causes of pityriasis rosea are not clearly known, but some viruses are suspected of causing the infection (Halder & Nootheti, 2014).

Lupus. This is an autoimmune infection that occurs when the immune system attacks the body’s tissues and organs (Halder & Nootheti, 2014). Lupus causes an inflammation that may affect the skin, lungs, brain, kidneys, or joints (Halder & Nootheti, 2014). Lupus can be difficult to diagnose since it affects various body parts, and the symptoms vary from the type of lupus (Halder & Nootheti, 2014). Some symptoms of Lupus include red skin lesions that appear in areas exposed to the Sun., butterfly-shaped rashes in various body parts, fever, fatigue, chest pain, dry eyes, and headaches (Halder & Nootheti, 2014).

Guttate psoriasis. This is a form of a skin condition that appears as a red small itchy lesion (Dains, Baumann, & Scheibel, 2015). It is a form of an autoimmune disease that might occur more than once in a lifetime (Dains et al., 2015). Gutate psoriasis usually occurs on the face, ears, scalp, neck, legs, and arms (Dains et al., 2015). Guttate psoriasis is usually caused by bacterial infections, especially streptococcus (Dains et al., 2015). In some cases, genetic factors can play a role if there are several family members with the condition (Dains et al., 2015).

Patient’ problem/diagnosis:

Granuloma annulare. This a skin condition that causes circular reddish lesions. It is usually triggered by skin injuries or particular drugs (Halder & Nootheti, 2014). The condition may disappear on its own after approximately two years without treatment (Halder & Nootheti, 2014). However, treatment can help speed up healing. The symptoms of granuloma annulare depend on the type of infection (Halder & Nootheti, 2014). For example, localized granuloma annulare causes skin-colored lesions that occur on the feet, wrists, and hands (Halder & Nootheti, 2014). Generalized granuloma annulare causes red lesions on areas such as the neck, legs, and arms (Halder & Nootheti, 2014). The lesions in granuloma annulare are usually annular bumps that might spread to various parts of the body (Halder & Nootheti, 2014).

 Discussion:

Making a diagnosis for skin conditions can be difficult since the symptoms are often similar to those of other conditions. In the case of this discussion, it is particularly difficult because the patient was not physically present, and the diagnosis depended on an image interpretation.  The selected primary diagnosis for this discussion was granuloma annulare because the patient had symptoms of non-scaly annual papules distributed along his nape. The symptoms are similar to what shows in cases of granuloma annulare.  However, it is also possible for the patient to have conditions such as tinea corporis, pityriasis rosea, and lupus because the conditions also manifest red circular lesions in some cases. Therefore, further lab assessment and physical exams may be needed for an accurate diagnosis.

References

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2015). Advanced Health Assessment & Clinical Diagnosis in Primary Care-E-Book. Elsevier Health Sciences.

Halder, R. M., & Nootheti, P. K. (2014). Ethnic skin disorders overview. Journal of the American Academy of Dermatology, 48(6), S143-S148.

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