Health Assessment Skin Condition PDF

Preview

Summary

Focused soap note on skin condition...

Description

SOAP NOTE Differential Diagnosis for Skin Conditions Skin Condition Picture # 5

Patient Initials: __AJ___ Gender: __F___

Age: __24___

SUBJECTIVE DATA: Chief Complaint (CC): Painful rash and joint pain History of Present Illness (HPI): Anna James is a 24-year-old Caucasian female who presents today with a new onset of a painful plaque-like rash and joint pain 3 weeks ago. She reports she first noticed the rash on her knees and it has now developed on her elbows and scalp. She also reports that the rash is sore and slightly itchy. Anna has also noticed achy joints as well throughout the last 3 weeks. She reports that stressful situations seem to exacerbate the issue. She has changed laundry detergent and noticed no improvements in the rash, and she has also been taking Ibuprofen 400mg 3 times a day most days with little relief in pain. Anna reports the severity of her rash and joint pain to be 6/10. Medications: 1 Over-the-Counter Ibuprofen 400mg PO every 6 hours as needed 2 Women’s Multivitamin 1 tablet PO daily 3 Ortho Tri-Cyclin 1 tablet PO daily

Allergies: No known drug or food allergies.

Past Medical History (PMH): 1 Varicella 2 Recurring tonsillitis 3 Appendicitis

Past Surgical History (PSH): 1 Tonsillectomy 2001 2 Appendectomy 2004

Sexual/Reproductive History: Heterosexual G0P0A0 Menarche at age 11 Patient reports regular menses Currently sexually active and has been on oral contraception regimen for 7 years Denies any risky sexual behavior Last Pap smear was in 2014 with normal results Personal/Social History: Patient denies tobacco, ETOH, or illicit drug use. She states she exercises regularly and maintains a healthy diet. Immunization History: Her immunizations are up to date. Her last Tdap was in 2010 and she has received her flu vaccine for this year. She does not meet criteria for receiving the pneumonia vaccination at this time. Significant Family History: Mother, age 45, has history of breast cancer in 2007-currently in remission. Father, age 50, has history of eczema and multiple allergies. Maternal grandfather, age 71, has history of psoriasis and psoriatic arthritis. Paternal grandmother, age 73, has history of eczema and psoriasis. Two brothers aged 16 and 20 have recent history of fungal

infection-type unknown. Lifestyle: She is beginning a career in cosmetology after recently graduating from a local community college and passing the state licensing exam 2 weeks ago after 2 failed attempts. She is currently searching for her own apartment close to her new job. The home she currently lives in is cramped, as her mother just had a child 1 month ago and is hoping to use her room for the newborn’s nursery. Due to these factors, Anna sleeps on the couch most nights and often stays up late helping with the baby. Anna is currently under her parent’s health insurance plan and has regular health check-ups. Her diet and exercise regimens are healthy. She admits her support system is strained at this time, as her family is busy with the new baby and she hasn’t made friends at her new job yet. 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: Negative for fatigue, fever, chills, night sweats, or significant weight changes HEENT: No changes in vision or hearing. Negative for blurred or double vision, tinnitus, discharge from ears. Her last visual exam was in 2015. Negative for vertigo, nosebleeds, or postnasal drip. Negative for sore throat, bleeding gums, ulcers, or tooth problems. Last dental exam was 3 months ago. Musculoskeletal: Positive for diffuse joint pain (see HPI), negative for history of gout, arthritis, trauma, or fractures. Psychiatric: Positive for sleep disturbances, socialization issues, and increased stress. No history of anxiety or depression. Denies any suicidal thoughts.

Skin: Positive for sore, pruritic, polycyclic salmon-colored plaques located on the scalp, elbows, and knees bilaterally. Plaques are approximately 1 cm in size. Negative for pigment changes. Allergic/Immunologic: No known history of drug, food, or seasonal allergies. No known immunologic disorders. OBJECTIVE DATA: Physical Exam: Vital signs: T- 97.8 tympanic; P- 82, regular; BP 112/68 right arm, sitting, regular adult cuff; RR- 17, non-labored; Pain 6/10; Ht: 5’7” Wt: 130 lbs BMI: 20 General: AAOx3. Well nourished, well groomed. No apparent distress. Appears uncomfortable. Normal gait. HEENT: PERRLA, EOMI, oronasopharnyx clear with no redness or swelling. Musculoskeletal: Symmetric muscle development, mild swelling of wrist, knee, and ankle joints bilaterally with pain present. Skin: Several areas of salmon-colored, silvery, polycyclic plaques located on the scalp, elbows, and knees, all about 1cm in size with discrete borders. Sore and slightly painful to palpation. No other rashes or cyanosis. Thick acrylic nails present, limiting nail assessment. Lab Tests and Results: CBC- WBC 8,000 Diagnostics: Skin biopsy- negative for fungal infection, positive for psoriasis. ASSESSMENT: Priority Diagnosis: Psoriasis

Differential Diagnoses: 1 Eczema 2 Lichen Planus 3 Mycosis Fungoides

When considering the patient’s symptoms and the description of the rash presented, it becomes quite clear that the patient is suffering from psoriasis. The strong family history of psoriasis and recent life stressors put the patient at a high risk for developing psoriasis (Ely & Stone, 2010). The patient’s complaint of joint pain also points toward a diagnosis of psoriasis, as the patient may be suffering from psoriatic arthritis, a complication of psoriasis. The description and location of the rash all point towards psoriasis as well (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Although Mycosis Fungoides presents in pink plaques, the differential diagnoses of Lichen Planus and Mycosis Fungoides can be ruled out after skin biopsy that reveals no fungal infection, as these conditions are both caused by fungi (Dains, Baumann, & Scheibel, 2016; Ely & Stone, 2010). Furthermore, Lichen Planus is characterized by a white plaque with net-like distribution, which is not found in the assessment (Ball et al., 2015). Eczema can be ruled out by the information provided and diagnostic testing, as well as the fact that plaques are not typically characteristic of eczema, unless there has been long-term scratching (Ball et al., 2015).

Skin Condition Picture # 2

Patient Initials: _JM___ Gender: __M__

SUBJECTIVE DATA:

Age: __46__

Chief Complaint (CC): New onset of rash History of Present Illness (HPI): Jerry Morgan is a 46-year-old Caucasian male who presents today with complaints of a new onset of a red rash that has developed over the past few days on his trunk area. He has noticed no associated symptoms, aggravating or relieving factors, and has not attempted any treatments of this rash. He states that the rash is not severe or impacting his daily life, but he is concerned that it may be something serious. Medications: 1 2 3 4

Metoprolol 25mg PO BID Pravastatin 40mg PO at bedtime Xarelto 20mg PO daily with dinner Over-the-Counter Pepcid AC 10mg PO daily

Allergies: Penicillins- rash, Sulfa drugs-rash, bees. Past Medical History (PMH): 1 2 3 4

Hypertension- well controlled Atrial Fibrillation- well controlled Gastroesophageal Reflux (GERD) – takes daily OTC acid reducer Dyslipidemia- well controlled

Past Surgical History (PSH): Tonsillectomy (1976) Vasectomy (2005) Cholecystectomy (2010) Total Knee Replacement (2014) Sexual/Reproductive History: Patient denies any reproductive issues or risky sexual behavior. Currently married with 4 children and has had a vasectomy. No history of STIs. Personal/Social History: Patient has smoked 1.5 packs of

cigarettes/day x 30 years; drinks 5-10 beers/week; admits to regular marijuana use x 30 years. Patient does not have regular exercise habits but considers himself fairly active through outdoor work and occasional kayaking/hiking trips; his diet is regular and he admits is not healthy, mainly consisting of fried, fatty foods. Immunization History: His last Tdap was in 2006 and he declines the Flu and Pneumonia vaccinations. Significant Family History: Father- Atrial Fibrillation, Hypertension, Myocardial Infarction, Diabetes-Type 2, Dyslipidemia –died at age 68 of heart attack. Mother- Ischemic Stroke, Hypertension, Dyslipidemia-died at age 70 from complications of stroke. Siblings- two sisters with history of hypertension and diabetes-type 2, one with history of breast cancer in 2006. Children-all healthy with no medical issues Lifestyle: He currently owns and operates his own pest control business and has for the past 15 years. He has been married once and has 4 children with his wife. They live in a suburban middleclass neighborhood with good transportation and school systems. He enjoys outdoor activities and often works on household issues in his free time. He has a strong support system through family and friends. He gets yearly check-ups for physical, vision, and dental health maintenance. 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: Negative for recent weight changes, fever, chills, night sweats, or changes in energy levels Respiratory: + for occasional productive cough with dark sputum in the mornings, denies any shortness of breath on exertion or exposure to tuberculosis Cardiovascular/Peripheral Vascular: Negative for chest pain, palpitations, edema, claudication, exercise intolerance. Gastrointestinal: + for heartburn; negative for nausea, vomiting, bowel changes Skin: + for ruby red papular rash on trunk, denies pruritus, pain, eruptions, or pigmentation changes. Hematologic: + for prolonged bleeding times and easy bruising, negative for anemia Allergic/Immunologic: + for drug allergies to penicillin and sulfa drugs, bees. Denies any recent new drug use. No current issues. OBJECTIVE DATA: Physical Exam: Vital signs: T- 98.9 oral; P- 72, irregular; BP- 128/72 left arm, sitting, long cuff; RR- 18; Pain 0/10 Ht: 6’2” Wt: 210 lbs BMI: 27 General: AAO x3, moves all extremities, gait normal, well developed, well nourished, not malodorous. Appears comfortable and not in any apparent distress. Chest/Lungs: Breath sounds clear and equal AP&L bilaterally Heart/Peripheral Vascular: Irregular rhythm, controlled rate. No murmur, rub, or gallop. Pulses +2 bilateral radials and +2 bilateral pedals. Abdomen: Bowel sounds present x4 quadrants. Soft, non-tender, non-distended. No organomegaly. Skin: Ruby red papular rash on the trunk with no itching or pain present. No edema, clubbing, or cyanosis. No palpable nodules.

Lab Tests and Results: CBC- RBC 5.7, PLT 250, HGB 15, HCT 44 PT/INR- 22/2.1 PTT- 27 sec. ASSESSMENT: Priority Diagnosis: Cherry Angioma Differential Diagnoses: 1 Drug eruption 2 Pityriasis Rosea 3 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...