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NURS 6512 >Wk 4 SOAP Note
- 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 3 different references from current evidence based literature. Comprehensive SOAP Patient Initials: JJ (^) Age: 54 Gender: M SUBJECTIVE DATA: Chief Complaint (CC): Small, itchy, raised patches on lower back History of Present Illness (HPI): Jeremiah Jergens is a 54-year-old Caucasian male who presents today with a large cluster of thick, red, raised patches on his lower back. Jeremiah first noticed the patches 4 years ago, a few days after he recovered from a strep throat infection. He has associated symptoms of tenderness, itchiness and flaking of the patches. They often bleed when he accidently scratches off a patch. He reported the he is “embarrassed by the look of it” and will not take his shirt off at the beach. He has also noticed both his knees, joints in his fingers and back are very stiff in the mornings but lessens after walking and using his joints for a bit. He has been using Tylenol to help with the joint pain and for the patches, he reports using Benadryl ointment for the itching. Both provide minimal relief. He rates his discomfort a 4/10 today but in mornings 7/10 due to the joint pain.
Medications:
- Over-the-counter Tylenol 500mg PO once daily in the morning
He is married to his wife of 32 years. Together they travel the country in their RV and motorcycles. He has owned his home for the past 28 years in the suburbs. At 25 years as a U.S. Marine, he retired and receives full benefits of $75,000 annually. He and his wife both receive social security benefits. No financial issues. First born daughter rents the basement with her 2 children ages 5 and 12. Following his gastric bypass surgery, his health taken a turn for the better by decreasing his meat and increasing his vegetable intake. His total weight loss since the surgery is 143 lbs. He is now only taking one blood pressure medication, down from two. 5 days a week, he exercises at the local YMCA. When he is not traveling the country, he attends church Mondays and Thursdays for Bible study. He also leads the marriage ministry for newlyweds. He has a great support system including his friends and family. Review of Systems: General: Negative for recent sudden weight changes, weakness, fatigue, anorexia, malaise, or fever HEENT: negative for headache, head injury, visual changes, blurring of vision, itching, last eye exam 2/15/18. Negative for diplopia, floaters, loss of any visual fields, history of cataracts or glaucoma, pain, redness, excessive tearing. Negative for tinnitus, recent ear infections, hearing loss, change in hearing. Negative for epistaxis, frequent colds, nasal congestion, discharge, pain, post- nasal drip, change in ability to smell, history of nasal polyps, hay fever, and sinus trouble. Negative for mouth soreness, dryness, bleeding gums, throat soreness, pyorrhea, ulcers, and teeth dentures. Positive for recurrent strep throat infections ( within 5 months) and dental caries. Neck: negative for painful lymphnodes, enlarged lymphnodes, goiter Breasts: negative for new or changing breast lumps, nipple changes or nipple discharge, gynecomastia Respiratory: negative for cough, hemoptysis, wheezing, shortness of breath, dyspnea, pleuritic chest pain, cyanosis, recurrent pneumonia, environmental exposure, history of exposure to TB, last TB skin test 4/3/17-negative Cardiovascular/Peripheral Vascular: negative for chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, edema, palpitations, murmur, varicosities, history of rheumatic fever, syncope, claudication, thrombophlebitis. Positive for hypertension and
history of abnormal electrocardiogram
Wt 196 lb (85 kg) | BMI 24 kg/m²
General: Alert and orientated to time, place, and person, well appearing, and in no distress. Appears comfortable during history taking HEENT: Skull normocephalic, atraumatic, sparse hair with balding. PERRLA, light reflex present, oronasopharynx is clear Neck: supple, no palpable thyroid, midline trachea, no enlarged neck nodes, bruit, jugular vein distension, tmegally Chest/Lungs: clear to auscultation, no wheezes, rales or rhonchi, rubs, symmetric air entry, resonance on percussion, fremitus on palpation Heart: normal rate, regular rhythm, normal S1, S2, no murmurs, thrills, rubs, clicks or gallops Peripheral Vascular: peripheral pulses normal, no pedal edema, no clubbing or cyanosis Abdomen: Abdomen soft, nontender, nondistended, no scars, masses hernia, aortic pulsations, or organomegaly, bowel sounds present Genital/Rectal: No penile lesions or discharge, testicular lump, no hernias, uncircumcised. Rectal exam: negative without mass, lesions or tenderness. Musculoskeletal: Bilateral knee exam –positive for crepitation on left knee, no swelling good ROM right knee -no swelling, no crepitation good ROM. Muscle strength symmetric 5/5 all groups. Positive for mild swelling in joint of all fingers Neurological: reveals alert, oriented, normal speech, no focal findings or movement disorder noted. Gait regular, no involuntary movements. Cranial nerves II-XII grossly intact, DTR’s intact Skin: normal coloration and turgor, has benign small moles on chest, has cluster of well-demarcated red plaques >20% BSA macules and coarse scales on lower back, elbows, and along hairline (Gladman, Shuckett, Russell, Thorne, & Schachter, 1987). Onycholysis, thickening, and pitting of fingernails (Mcgonagle, 2009). ASSESSMENT: Lab Test and Results:
- Skin biopsy and Periodic acid–Schiff–diastase (PAS-D) stain –
- Nail culture using Potassium hydroxide (KOH) preparation – negative for nail fungus
- Auspitz sign – positive (Bernhard, 1990)
- Radiology -- “pencil-in-cup” phenomenon in both index fingers and right ring finger (Siannis, Farewell, Cook, Schentag, & Gladman, 2006).
- Serum Urate – 5.2 mg/dL Priority Diagnostics: A. Chronic Plaque Psoriasis B. Nail Psoriasis C. Psoriasis Arthritis Differential Diagnosis (DDx): A. a. Nummular eczema b. Seborrheic Dermatitis c. Atopic Dermatitis B. a. Superficial fungal infection b. Onychomycosis c. Lichen Planus C. a. Rheumatoid Arthritis b. Reactive Arthritis c. Gout Diagnoses/Client Problems:
- HTN, controlled
- Allergy to Penicillin (rash), salmon (anaphylaxis), peaches (lip itching), controlled References Bernhard, J. D. (1990). Auspitz sign is not sensitive or specific for psoriasis. Journal of the American Academy of Dermatology, 22 (6), 1079-1081. doi:10.1016/0190- 9622(90)70155-b Gladman, D. D., Shuckett, R., Russell, M. L., Thorne, J. C., & Schachter, R. K. (1987). Psoriatic arthritis (PSA) - An analysis of 220 patients. QJM: An International Journal of Medicine , 62(238-241), 127.
- doi:10.1093/oxfordjournals.qjmed.a
