Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

Patient Initials: ___A.B.____             Age: ___56____         Gender: ___Male____

SUBJECTIVE DATA:

Chief Complaint (CC): The patient presented to the clinic with a complaint of unrelenting sore throat, and the presence of an irregular dark spot on the skin of the forearm. The spot keeps changing in shape and size.

History of Present Illness (HPI): Patient A.B is a 56 year-old Caucasian male who came in with a sore throat that was not responding to treatment and an irregular and discoloured lesion on the forearm. These symptoms started four weeks before and have been persistent ever since. The throat is painful and the discoloured lesion is irregular and expanding. The sore throat is aggravated by spicy foods and slightly relieved by taking cold fluids. He was treated previously with amoxicillin 500 mg TDS for one week but there was no response. He rates the severity of the sore throat, the lesion, and his discomfort at 6/7. Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

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Medications:

  1. Dyclonine (Cepacol) spray daily
  2. Acetaminophen 500 mg PRN
  3. Betamethasone topical cream applied TDS

Allergies:

  1. NKDA
  2. No allergies to food and food products

Past Medical History (PMH):

  1. Hypertension that is currently well controlled.
  2. Pneumonia – admitted for one week in 2015.
  3. PUD on H2 receptor blockers, currently with no symptoms.
  4. Lymphogranuloma venereum in 1999 (treated) and Donovanosis in 2001 (treated).

Past Surgical History (PSH):

  1. Herniorrhaphy (inguinal) in 1992.
  2. Splenectomy in 2005.

Sexual/Reproductive History:

  2. Vasectomy (2000).

Personal/Social History:

He denies smoking or a history of the same. Also denies etoh or the use of any substances of abuse. Patient can carry out ADLs unassisted and is able to do isotonic aerobic exercise (daily walking in the park) as a routine. He does not eat meat but consumes sufficient amounts of fresh fruits and vegetables. He routinely takes three meals in a day but rarely eats or drinks anything in-between, except water.

Immunization History:

His immunizations are up to date. Last booster Tdp received in 2009. Influenza and pneumococcal vaccines received in February 2020.

Significant Family History:

He has one elder sibling – a sister who is married with a grown son. She has type II diabetes mellitus dx at the age 40 years. Both of his parents are deceased from natural causes. His only daughter is healthy and currently living in another state.

Lifestyle:

Patient A.B. is a retired educator currently relying on his pension. He is however financially stable and can meet his needs. He is a divorcee (2007) living currently in a suburban neighborhood with good amenities and security. He is close to his elder sister whose children also visit him regularly as is his own daughter.

Review of Systems:

General: Reports fatigue and some weakness though denies fever, chills or diaphoresis at night. He denies any recent weight changes.

HEENT: No short-sightedness, no hearing loss, otorrhea or tinnitus, and does not wear glasses or hearing aids. His last ear examination was 8 months ago. He denies photophobia, excessive tearing or diplopia. Denies having epistaxis and confirms that his sense of smell is intact. He denies nasal polyps, rhinorrhea, or a history of allergic rhinitis. He denies gingivitis, oral ulceration, or bleeding of the gums. He does not have any dental appliances and his last dental check-up was six months ago. He however accepts pain in the throat (sore throat) that is persistent and causes dysphagia.

Neck: Full range of motion. He has no history of disc compression or prolapse.

Breasts: Denies any rashes or lumps on the breasts.

Respiratory: He denies any cough, phlegm, hemoptysis, or dyspnea.

Cardiovascular/Peripheral Vascular: He denies chest pain or discomfort of any kind. He has no history of peripheral edema, or intermittent claudication.

Gastrointestinal: He denies having nausea or vomiting. Also denies abdominal pain or any changes in bowel habits. He had his latest bowel movements in the morning before coming to the hospital.

Genitourinary: He denies dysuria, frequency of micturition, polyuria, or oliguria. He also denies incontinence. He is heterosexual but was vasectomised in the year 2000. He is occasionally sexually active as he has a girlfriend he sees not so often. He admits to an extensive history of STIs.

Musculoskeletal: He denies any joint pains or arthralgia. Also reports no myalgia. He has a full range of motion and has no history of factures or trauma.

Psychiatric:  He denies any history of mental illness or conditions such depression or anxiety. He denies insomnia and homicidal or suicidal ideation.

Neurological: He denies any history of fainting or dizziness. He also denies ataxia or an alteration in the level of consciousness. He has not had any seizures or unexplained falls.

Skin: He reports a discoloured lesion that is irregular and growing on his right forearm. It does not itch but is slightly painful.

Hematologic: he denies any history of blood cancers in the family. Also denies any blood disorders or clotting difficulties.

Endocrine: He denies any hormonal therapies, excessive thirst, excessive sweating, or heat intolerance.

Allergic/Immunologic: e has no known history of immunodeficiency and was last tested for HIV in the year 2010. The test was negative.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 120/80 regular cuff and sitting; P 72, regular; T 98.2°F; RR 15, non-labored; BMI 24.5 kg/m2 (normal).

General: A&O x 3, well-groomed.

HEENT: PERRLA, EOMI, but oronasopharynx shows inflammation and rosy discoloration. No exudate noted.

Neck: No jugulovenous distension or carotid bruit. No cervical lymphadenopathy.

Chest/Lungs: Ling fields clear. No crepitations, rhonchi, or rales.

Heart/Peripheral Vascular: S1 and S2 audible and RRR with no murmurs. No gallop or rub.

Skin: There is a mole measuring about 2 cm by 3 cm on the right forearm. It is irregular with rough and notched borders. It has uneven dark spots and is tender to touch.

ASSESSMENT:

Lab Tests and Results

  • CBC 7,600; RBC 5.69
  • SpO2 99%

Diagnostics:

  • Lab: CRP 3 mg/L; WBC 7,600 (no leucocytosis)
  • Radiology: CXR normal chest radiograph.

Differential Diagnoses

  1. Cutaneous melanoma (image 1). The ABCDE method of physical examination for the lesion on patient A.B.’s right forearm is positive for cutaneous melanoma (irregular shape, irregular ages, uneven dark spots, and a large diameter) (Hammer & McPhee, 2018; Leonardi et al., 2018; Jameson et al., 2018; Huether & McCance, 2017).
  2. Seborrheic keratosis (Jameson et al., 2018).
  3. Dermatofibroma (Jameson et al., 2018).

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

O = onset of symptom (acute/gradual)

L= location

D= duration (recent/chronic)

C= character

A= associated symptoms/aggravating factors

R= relieving factors

T= treatments previously tried – response? Why discontinued?

S= severity

 

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.

 

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom: Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

  1. Location
  2. Quality
  3. Quantity or severity
  4. Timing, including onset, duration, and frequency
  5. Setting in which it occurs
  6. Factors that have aggravated or relieved the symptom
  7. Associated manifestations

 

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

 

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

 

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

 

Past Surgical History (PSH): Include dates, indications, and types of operations.

 

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

 

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

 

Immunization History: Include last Tdp, Flu, pneumonia, etc.

 

Significant Family History: Include history of parents, Grandparents, siblings, and children.

 

Lifestyle: Include cultural factors, economic factors, safety, and support systems.

 

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

 

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

            HEENT:

Neck:

            Breasts:

            Respiratory:

            Cardiovascular/Peripheral Vascular:

            Gastrointestinal:

            Genitourinary:

            Musculoskeletal:

            Psychiatric:

            Neurological:

            Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.

            Hematologic:

            Endocrine:

            Allergic/Immunologic:

 

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

 

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things. Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

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HEENT:

Neck:

Chest/Lungs: Always include this in your PE.

Heart/Peripheral Vascular: Always include the heart in your PE.

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

 

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

 

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

 

Treatment 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 the 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 the disease prevention recommendations and strategies with evidence and guidelines.

 

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?

Ball: Seidel’s Guide to Physical Examination, 8th Edition

 

Chapter 08: Skin, Hair, and Nails

 

Key Points

 

This review discusses examination of the skin, hair, and nails.

  • Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass or dermatoscope; and Wood’s lamp.

 

To examine the skin, perform the following.

  • Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.
  • During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.
  • Inspect the skin in two ways.
  • First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences among body areas, and compare sun-exposed areas with areas that were not exposed to the sun.
  • Second, observe the skin as each part of the body is examined.
  • When evaluating the skin and mucous membranes in each part of the body, note six characteristics.
  • The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.
  • The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.
  • The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is at areas of pressure or rubbing, such as the elbows, soles, and palms.
  • The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.
  • The fifth characteristic is hygiene, which may contribute to skin condition.
  • The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.
  • During inspection, also palpate the skin to determine five characteristics.
  • First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.
  • Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm but should be bilaterally symmetrical.
  • Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.
  • Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.
  • If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined. Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note
  • First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.
  • If the lesion has exudates, note their color, odor, amount, and consistency.
  • If there is more than one lesion, describe their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.
  • Record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.
  • Use a light and magnifying glass to determine the lesion’s subtle details, including color, elevation, and borders.
  • To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.
  • To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection.

 

To examine the hair, perform the following.

  • To assess the hair, palpate its texture. Scalp hair may be coarse or fine and curly or straight. It should be shiny, smooth, and resilient.
  • During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.
  • Hair color ranges from very light blond to black to gray.
  • Hair distribution and quantity vary with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.

 

To examine the nails, perform the following.

  • Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.
  • Inspect the nails for six characteristics: color, length, condition, configuration, symmetry, and cleanliness.
  • Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.
  • The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.
  • In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.
  • The nails should appear bilaterally symmetrical.
  • The nails should be clean, smooth, and neat.
  • Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.
  • The nail-base angle should measure 160 degrees.
  • If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.
  • Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.
  • Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.
  • The texture of the nail plate should be hard and smooth.
  • The nail base should be firm—not boggy.
  • The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.
  • The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad. Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel's guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. Elsevier, Inc.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20th ed. McGraw-Hill Education.

Leonardi, G., Falzone, L., Salemi, R., Zanghï, A., Spandidos, D., McCubrey, J., Candido, S., & Libra, M. (2018). Cutaneous melanoma: From pathogenesis to therapy (Review). International Journal of Oncology, 52(4), 1071-1080. http://dx.doi.org/10.3892/ijo.2018.4287   Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note