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.
SOAP Notes for Differential Diagnosis of Skin Lesions
Comprehensive SOAP
Patient Initials: ___ABC____ Age: ___37___ Gender: ____Female___
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. Graphic Image Number #5 (Dains et al., 2019)
History of Present Illness (HPI):
ABC is a 37-year-old female of Cuban Hispanic origin. The patient presented at the clinic with skin lesions comprising of plaques that have silvery-white scaly, erythematous plaques. The plaques were not only sharply demarcated but also indurated over the last two weeks. The lesions have no definitive shape or size ad manifest as multiple pinkish-red plaques. In the graphic picture #5, the scales appear to be emanating and extending into one another, making them seem to appear to cover a large area. ABC reports the husband told her she several red moles on her back before some of them spread to her chest area two days later. The lesions appear like endothelial cells proliferation. The lesions appeared after she stopped taking the pill because she wanted to have a baby a month ago.
(SOAP Notes for Differential Diagnosis of Skin Lesions)
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Medications: No prescribed medication nor over the counter medication.
Allergies: Has no known drug allergy.
Past Medical History (PMH):
She denies any serious childhood and has never had any hospital admissions that she knows of. She even never had premarital sex and is faithful to her husband.
Past Surgical History (PSH): three years ago, she had minor surgery to remove atypical moles for melanocytic nevi from her left-hand fingers. Furthermore, it was not necessary to have a re-excision as recommended after the biopsy. She was advised to take annual skin exams which she did not adhere to.
(SOAP Notes for Differential Diagnosis of Skin Lesions)
Sexual/Reproductive History: If applicable,
She had her first menses at the age of 12 years, uses the pill as her preferred contraception and has two teenagers both delivered naturally.(SOAP Notes for Differential Diagnosis of Skin Lesions)
Personal/Social History:
She reports she is a teetotaller.
Immunization History: Received the normal childhood immunization schedule and flu and tetanus are up to date.
Significant Family History: Negative for melanoma
Lifestyle: Normal lifestyle
Review of Systems: All are normal except the current skin lesions.
OBJECTIVE DATA:
Oriented and Alert x4. ABC displays a normal mood and conventional body habits. I assessed her neck, face, chest, abdomen, breasts and back. The chest area and her back had lesions. Additionally, I also assessed her upper and lower extremities bilaterally, and all were negative for irritating cutaneous malignancy. However, inflammatory cherry –red papules appear due to proliferation of dilated small veins on her upper back. Be that as it may, the patient has many inflammatory cherry –red papules appear
(SOAP Notes for Differential Diagnosis of Skin Lesions)
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Physical Exam:Vital signs: Ht 5 feet 3 inches, Wt. 140 pounds BMI I24.8
General: NAD, well-groomed
HEENT: Normal
Neck: No noticeable or palpable swelling
Chest/Lungs: Always include this in your PE. No chest pain
Heart/Peripheral Vascular: Always include the heart in your PE. No SOB, chest pain or palpitations
Abdomen: Normal bowel sounds, soft and no tender
(SOAP Notes for Differential Diagnosis of Skin Lesions)
Genital/Rectal: No rectal exam performed as no symptom warranted it
Musculoskeletal: No changes in strengths, no joint tenderness or swellings
Neurological: No memory alterations
Skin: skin lesions
ASSESSMENT:
It is challenging to establish the specific condition responsible for the condition that causes to the skin abnormality in picture 5 (Luna et al., 2016). The papules may have emerged spontaneously, progressively or in an aggressive eruptive way. They could also have emanated from the development of new blood vessels from those already existing hence angiogenesis (Fallah et al., 2019).
(SOAP Notes for Differential Diagnosis of Skin Lesions)
To begin with, there is a likelihood that the lesions in #5 could be the result of an insect bite. However, the severity of the skin lesions would vary depending on the type of inset involved and the number of times. The insect that could bite the skin if not lice, flea or bed bug infestation is unlikely to target the affected location of the skin. The second cause could be miliaria crystalline, where the papules are clustered in the same region, and their size appears to be very minute (Kumar et al., 2014). The third likely cause could be Kaposi sarcoma which is skin disorder whose clinical manifestation include reddish to bluish cutaneous nodules.
(SOAP Notes for Differential Diagnosis of Skin Lesions)
However, the likely cause of the skin lesions in #5 is an abnormal proliferation of blood vessels hence the positive cherry angioma and mild truncal acne after the woman stopped taking the pill to fall pregnant after sexual intimacy. The skin condition is most prevalent in adults above the age of 30 years, and the number of papules seems to increase with advancing age.
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SOAP Notes for Differential Diagnosis of Skin LesionsTreatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support disease prevention recommendations and strategies with evidence and guidelines.
(SOAP Notes for Differential Diagnosis of Skin Lesions)
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th Ed.). St. Louis, MO: Elsevier Mosby
Fallah, A., Sadeghinia, A., Kahroba, H., Samadi, A., Heidari, H. R., Bradaran, B., & Molavi, O. (2019). Therapeutic targeting of angiogenesis molecular pathways in angiogenesis-dependent diseases. Biomedicine & Pharmacotherapy, 110, 775-785.
Kumar, S., Mahajan, B. B., Kaur, S., & Singh, A. (2014). Erythropoietin induced miliaria crystallina: A possible new adverse effect of erythropoietin. Int J Case Rep Images, 5(9), 634-637.
(SOAP Notes for Differential Diagnosis of Skin Lesions)
Luna, P. C., Boggio, P., & Larralde, M. (2016). Dermatologic aspects of Fabry disease. Journal of Inborn Errors of Metabolism and Screening, 4, 2326409816661353…
Question – SOAP Notes for Differential Diagnosis of Skin Lesions
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.
(SOAP Notes for Differential Diagnosis of Skin Lesions)
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.
Below are 3 references are from this week\’s learning resources, you only need 2 of them.
Also, there also needs to be 1 different reference from evidenced-based literature.(SOAP Notes for Differential Diagnosis of Skin Lesions)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
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