Skin Comprehensive SOAP Note

Skin Comprehensive SOAP Note:
LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS
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• Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
• In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
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• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
• Consider which of the conditions is most likely to be the correct diagnosis, and why.
• Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
• Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
• Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

• 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 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.

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Patient Initials: JM Age: 45 Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): Rash on face

History of Present Illness (HPI): Patient reports that the rash started two weeks ago and has been gradually worsening. He describes the rash as red, itchy, and scaly. The rash is primarily located on his cheeks and forehead, but has started to spread to his nose and chin.

Medications: None

Allergies: None

Past Medical History (PMH): Hypertension

Past Surgical History (PSH): None

Sexual/Reproductive History: Not applicable

Personal/Social History: The patient works in construction and is frequently exposed to sun and wind.

Health Maintenance: Up to date on all recommended screenings and immunizations.

Immunization History: Up to date on all recommended immunizations.

Significant Family History: No significant family history.

Review of Systems: General: No significant findings. HEENT: As noted in HPI. Respiratory: No significant findings. Cardiovascular/Peripheral Vascular: No significant findings. Gastrointestinal: No significant findings. Genitourinary: No significant findings. Musculoskeletal: No significant findings. Neurological: No significant findings. Psychiatric: No significant findings. Skin/hair/nails: As noted in HPI.

OBJECTIVE DATA:

Physical Exam:
Vital signs: Blood pressure 138/82 mmHg, heart rate 84 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F.
General: The patient is alert and oriented, in no apparent distress.
HEENT: The patient has a red, scaly rash on his cheeks and forehead, spreading to his nose and chin. The rash appears to be slightly raised and has a rough texture.
Neck: No significant findings.
Chest/Lungs: No significant findings.
Heart/Peripheral Vascular: No significant findings.
Abdomen: No significant findings.
Genital/Rectal: Not applicable.
Musculoskeletal: No significant findings.
Neurological: No significant findings.
Skin: As noted in HEENT.

Diagnostic results: None

ASSESSMENT: Based on the patient’s history and physical exam, the most likely diagnosis is seborrheic dermatitis.

PLAN:

Educate patient on seborrheic dermatitis and its management.
Prescribe topical antifungal and corticosteroid cream.
Instruct patient to avoid triggers such as harsh soaps, cold weather, and stress.
Follow-up appointment in two weeks to assess response to treatment.
References:

James, W. D., Berger, T. G., & Elston, D. M. (2020). Andrews’ Diseases of the Skin E-Book: Clinical Dermatology. Elsevier Health Sciences.

Chosidow, O. (2006). Scabies and pediculosis. The Lancet, 367(9524), 1767-1774.

Elewski, B. E. (2010). Tinea capitis: a current perspective. Journal of the American Academy of Dermatology, 62(3), 375-384.