Differential diagnosis for skin conditions soap note example

SOAP NOTE

Differential Diagnosis for Skin Conditions

Skin Condition Picture # 2

Patient Initials: __JB___ Age: __47___ Gender: __M___

SUBJECTIVE DATA:

Chief Complaint (CC): Red lesions on trunk of body

History of Present Illness (HPI): Joe Brown is a 47-year-old Caucasian male who presents to practice with complaints of red lesions on the trunk area. The red lesions developed two weeks ago

of his body. The patient has not reported any irritating or soothing factors, and he has not tried any treatment for the lesions. Joe Brown reports the lesion does not affect his daily lifestyle and in not impacting in a negative way. Joe is just worried it could be something more severe. differential diagnosis for skin conditions soap note example

Medications:

Lopressor 25mg twice daily
Lovastatin 40mg at bedtime
Xarelto 20mg daily with dinner

Allergies: Penicillins- rash,

Past Medical History (PMH):

Hypertension diagnosed at 44
Atrial Fibrillation diagnosed at 46
Dyslipidemia diagnosed at 42

Past Surgical History:

Vasectomy (2010)

herniorrhaphy (2008)

Sexual/Reproductive History: Patient denies any issues reproductively. Patient is currently divorced with 2 children and had a vasectomy in 2010. Patient has no history STDs and all sexual encounters have heterosexual.

Personal/Social History: Patient smoked 1 packs of cigarette/day x 10 years and drinks 2 bottles of beer a week for 26 year. Patient denies ever using recreational drugs. Patient does not exercise regularly but considers himself active due to the nature of his job (construction worker). Patient admits he does not follow a prescribed diet he still consume food high in fat and salt.

Immunization History: His immunization is up to date. He received his last flu shot and pneumonia vaccines in 2017 differential diagnosis for skin conditions soap note example

Significant Family History:

Father- Father is deceased, age 70, complications of type 2 diabetes

Mother- mother is deceased, 64, from hemorrhagic stroke

Siblings- two brothers with history of hypertension.

Children-2 children alive and well no significant medical issues.

Lifestyle: He currently works in the construction industry and has worked for in constructions for the past 20 years. He has been married once but currently is divorced and has 2 children with his wife. He lives in a middle-class neighborhood in the suburbs. He enjoys barbequing during his free time. He has a strong support system through his family and friends. Patient get a yearly physical check up but not vision and dental.

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 so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).

General: Mr. Brown is well-developed, well nourished Caucasian male who is alert and cooperative. He is negative for recent changes in weight, fever, chills or night sweats.

Respiratory: He denies SOB or exposure to tuberculosis.

Cardiovascular/Peripheral Vascular: Mr. Brown denies chest pain, palpitation or irregular rhythm. No history of edema, exercise intolerance and claudication.

Gastrointestinal: negative for heartburn; negative for nausea, vomiting, bowel changes. Bowel movements are solid and negative for frank blood.

Skin: Presence of ruby red papules on trunk, denies pruritus or pain.

Hematologic: Mr. Brown denies prolonged bleeding times and easy bruising. No history of anemia.

Allergic/Immunologic: Mr. Brown is allergic to penicillin. No asthma or atopy. Patient has never been tested for HIV. Patient denies any recurrent infections.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temp 97.0; P78 and regular; R 18 and regular BP 138/72 right arm. His weight is currently 190. Height 6’2”. BMI is 25.

General: Mr. Brown is well-developed, well nourished Caucasian male who is alert and cooperative.

Chest/Lungs: Breath sounds clear to auscultation in all lung fields. There is symmetry in chest wall expansion and diaphragmatic excursion.

Breast: No masses or sign of gynecomastia

Neck: Presesnce of full range of motion. Absence of carotid bruit and absence of mass.

HEENT:

Heart/Peripheral Vascular: Heart regular rate and rhythm. No heart murmur, rub, or gallop. Pulses +2 bilateral radials and +2 bilateral pedals. Absence of peripheral edema.

Abdomen: Bowel sounds present x4 quadrants. Soft, non-tender, non-distended abdomen. Absence of organomegaly or masses.

Skin: Tiny bright ruby-red, round papules on the trunk of Mr. Joe’s body. Turgor is good, no cyanosis or jaundice.

Lab Tests and Results:

CBC- RBC 4.7, PLT 200, HGB 13, HCT 44

Chemistry: triglycerides 455, LDL 198, Total cholesterol 234; otherwise WNL.

ASSESSMENT:

Priority Diagnosis: Cherry Angioma

Differential Diagnoses:

Drug eruption
Pityriasis Rosea
Thrombocytopenic purpura

The primary diagnosis selected in this patient is cherry angioma, as the clinical presentation and history best supports this diagnosis. The patient presented with a non-painful, non-pruritic papular rash limited to the trunk of the body with no other negative symptoms. A drug eruption could be responsible for a red rash on the patient’s trunk, but the patient denies any use of new medications and the rash is not generalized, pink, and morbilliform, how drug rashes usually are presented (Ball et al., 2015). Pityriasis Rosea meets some of the criteria, but the rash is not itchy, scaly, or in oval patches, and the patient denies any recent illnesses (Dains, Baumann, & Scheibel, 2016). Thrombocytopenic purpura is a contender for a priority diagnosis since the patient is on blood thinners and at risk for increased bleeding, but lab results show that platelet and other blood counts are within normal limits, and the rash is not generalized (Ball et al., 2015).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Ely, J. W., & Stone, M. S. (2010). The generalized rash: Part I. Differential diagnosis. American Family Physician, 81(6), 726-734. Retrieved from http://www.aafp.org/afp/2010/0315/p726.html

Comprehensive SOAP

Patient Initials: JS Age: 58yo Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): Skin abnormality appearance of a wide array of firm red bumps on chest and upper stomach (Slide #2) differential diagnosis for skin conditions soap note example

History of Present Illness (HPI): JS is a 58-year-old white male who appears today to address numerous red bumps on his chest that spreads down to his abdomen. He reports there is a gradual onset over the past few months and he did not have this many a few years ago. He is concerned he may have cancer since he asked some friends and they said it could be start of it. He denies any pain to the areas, exudate, bleeding, or change in shape. He denies any fever and no presentation to contact aggravations such as chemicals. States his job can be a little stressful at times but not too significant. No changes in lifestyle. He does not have any personal history of skin growths before other than moles but there is a family history of skin cancer.

Medications:

Celexa 20mg daily

Metoprolol 25mg BID

Allergies:

Amoxicillin

Past Medical History (PMH):

Depression: diagnosed at age 37

Hypertension: diagnosed at 46

Past Surgical History (PSH):

Lasik Eye Surgery (Dr. John Stefano, MD), age 47

Cholecystectomy (Dr. Anil Makani, MD), age 54

Appendectomy (Surgeon Unknown), age 16

Sexual/Reproductive History:

Heterosexual, he is currently sexually active with one partner. He uses no barrier

methods and his wife has entered menopause.

Personal/Social History:

Never smoked, occasional ETOH use (5 wine coolers per month), denies any use of illicit drugs

Immunization History:

His immunizations are up to date. He has not received the flu vaccination since last year and the Pneumococcal vaccine has not been administered. differential diagnosis for skin conditions soap note example

Significant Family History:

Mother deceased in February 2018 due to acute lung injury, father is still living; history of hypertension, skin cancer and prostate enlargement, two siblings who are without any medical issues. He has two sons and two daughters ages 34, 31, 21, and 18. All healthy and living nearby.

Lifestyle:

He is currently employed selling life insurance from his home office. He is married to his wife of 28 years and lives in his own home with her. He is currently sexually active. He has four children and four grandchildren, all live in close proximity. He is active to some degree. He takes walks with his wife 2-3 days a week. He attends chapter meetings monthly for his place of employment. He visits his father on a daily basis to assist him with any needs that he may have around his home.

Review of Systems:

General:

Mr. Shockey is a well-appearing Caucasian male who presents alert. He appears to have good hygiene. Denies fatigue, fever, chills, recent weigh gain or loss, or loss of appetite. Answers questions appropriately.

HEENT:

No vision or hearing impairments; he does not wear glasses other than for reading, + history of cataracts. His last eye exam was approximately one year ago. No recent hearing changes, discharge, ringing in the ears, or ear infections. He revealed his sense of smell is unblemished. No nasal or sinus issues. Nasal mucosa is pink without rhinorrhea or sinus delicacy. Oral mucosa clean, moist and intact. His last dental exam was 05/2018. Denies any concerns with chewing or swallowing.

Neck:

Supple, full scope of movement. No thyromegaly. No carotid bruits. No masses or tracheal deviation noted.

Breasts:

N/A

Respiratory:

Breath sounds are clear upon auscultation. Diaphragmatic excursion appears symmetrical. Denies any dyspnea on exertion, increased sputum production or cough. Denies ever having positive PPD.

Cardiovascular:

No chest pain, palpitations, + history of murmur as a child; no history of arrhythmias, edema, or pain with walking or varicosities.

Gastrointestinal:

No nausea, vomiting; + for occasional reflux. No abdominal discomfort, no changes in bowel pattern, denies any diarrhea, or constipation.

Genitourinary:

Urinary pattern is normal, denies any inability to urinate, or any form of incontinence, urgency or difficulty starting stream. He is heterosexual and is currently sexually active. No history of STDs.

Musculoskeletal:

Denies any bone or joint pain, no arthritis, gout and reports full ROM. No history of fractures or osteoporosis.

Psychiatric:

No history of anxiety. + history of depression for a number of years. No sleep disturbances or hallucinations. + for hospitalization to a psychiatric ward for symptom control of his depression and has received electrical shock therapy. He denies suicidal/homicidal ideation.

Neurological:

No syncopal episodes, + for dizziness when taking Celexa. No tingling or numbness, no headaches. + for change in thinking patterns and memory after his electrical shock therapy about 8 years ago. No tremors or abnormal movements; no history of gait issues or problems with coordination; he has been without falls and denies any type of seizure activity. differential diagnosis for skin conditions soap note example

Integumentary/Hematologic/Lymphatic:

+ for multiple 1-2 mm firm, elevated papules, appearing bright red, diffuse over his chest and upper abdomen, non-blanchable. No rashes, itching, or bruising. Denies any bleeding disorders, excessive bruising or blood transfusions.

Endocrine:

No endocrine issues or hormonal disorder.

Allergic/Immunologic:

+ history of generalized hives as a child after ingestion of amoxicillin.

OBJECTIVE DATA:

Physical Exam:

Vital signs: B/P 122/78, right arm, sitting, adult regular cuff; P 74 and regular; T 97.6 orally; RR 19; non-labored; Wt: 193 lbs; Ht: 6’1; BMI 25.5

General:

A&O x3, NAD, does not appear uncomfortable

HEENT:

PERRLA, Extra Ocular Muscle Intact, Ear canals patent. Nasal mucosa

pink, normal turbinates. No septal deviations. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth in good repair.

Neck:

Carotids no bruit, jugular vein distention or t-megally, Full ROM

Chest/Lungs:

Clear to auscultation AP&L, Symmetric chest wall, respirations non-

labored.

Heart/Peripheral Vascular:

RRR without murmur, rub, or gallop; S1 S2; +2 peripheral pulses bilaterally, no edema

Abdomen:

benign, normal bowel sounds in all 4 quadrants, no rebound tenderness, no masses.

Genital/Rectal:

Deferred at this time.

Musculoskeletal:

Symmetric muscle development; muscle strengths 5/5 all groups

Neurological:

CN II – XII intact, DTR’s intact, speech clear and in good tone.

Skin/Lymph Nodes: multiple 1-2 mm firm, elevated papule, color appears bright red, diffuse over the chest and upper abdomen, non-blanchable.

ASSESSMENT:

Diagnostics:

None required

Differential Diagnosis (DDx):

Glomeruloid hemangioma-Small, firm, red-to-violaceous, vault formed papules, papulonodules, subcutaneous pale blue compressible tumors, wine-red sessile or pedunculated papules, or injuries with cerebriform morphology. They extend in estimate, estimating couple of millimeters to couple of centimeters in distance across, and are found essentially on the storage compartment and proximal appendages and is portrayed by lone or numerous blue-red papules (Gupta, et al., 2013).
Petechiae is red to purple injuries showing up on the mucous films and skin. Injuries can be macular and discernable (American Academy of dermatology, n.d.). Petechiae is little sores estimating under 0.5 cm (Ball et al., 2015). differential diagnosis for skin conditions soap note example
Cherry angioma-Cutaneous vascular expansion which shows as single or different spots and happens transcendently on the upper trunk and arms. They regularly show up as round-to-oval, splendid, red, arch formed papules and pinpoint macules measuring up to a few millimeters in distance across. The histopathologic discoveries of a cherry angioma are steady with a genuine slim hemangioma, which is shaped by various, recently created vessels with thin lumens and unmistakable endothelial cells organized in a lobular manner in the papillary dermis. The etiology of cherry angiomas isn’t outstanding. In any case, since cherry angiomas tend to increment in number as the patient’s age expands, 75% of grown-ups more than 75 years old were seen in an ongoing report, the maturing process may assume a part in the pathogenesis of cherry angiomas (Sanz, et al., 2017).

Diagnosis/Client Problems:

Cherry Angioma – Cutaneous vascular expansion which shows as single or different spots and happens transcendently on the upper trunk and arms. They regularly show up as round-to-oval, splendid, red, arch formed papules and pinpoint macules measuring up to a few millimeters in distance across (Sanz, et al., 2017). Glomeruloid hemangioma is vascular multiplication and shows up all of a sudden on the storage compartment, furthest points, head, and neck area in this way it is discounted (Gupta, et al., 2013). Red to purple, hyperkeratotic and combining papules, happens most regularly on the lower locale of the trunk, hindquarters, and thighs and is normally connected with Lyosomal storage diseases. This was not observed at all and therefore is precluded.

Plan: Findings were presented to Mr. Shockey. In the event that treatment is wanted for corrective appearance, disturbance or bleeding; may allude to dermatology for electrocautery or laser treatment (Kim, 2009). Patient refuses as of now but may consider if any issues arise.

References

American Academy of Dermatology. (n.d.). Petechiae, purpura, and vasculitis.

Retrieved from file:///C:/Users/User/Downloads/Petechiae–Purpura-and-Vasculitis.pdf

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015).

Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid

hemangioma in normal individuals. Indian Journal of Dermatology, 58(2), 160. doi:10.4103/0019-5154.108088

Kim, J., Park, H., & Ahn, S. K. (2009). Cherry Angiomas on the Scalp. Case

Reports In Dermatology, 1(1), 82-86. Retrieved from Walden Library database

Sanz, V., Martorell, A., Alegria-Landa, V., Diaz, F. J., Torrelo, A., Alfaro-Rubio,

A., & Kutzner, H. (2017). Cherry hemanginomas and lipomas with peculiar distribution. Journal of the American Academy of Dermatology. 76(6). DOI: https://doi.org/10.1016/j.jaad.2017.04.280 differential diagnosis for skin conditions soap note example