NURS 6512N SOAP Note
Differential Diagnosis of Skin Conditions
SOAP NOTE and Siedel\’s Physical examination on Hair, Nails and skin
Solution
Student’s Name
Institutional Affiliations
Differential Diagnosis of Skin Conditions
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SOAP Note: Skin Conditions
Patient Initials: S. K. Age: 42 years old Race: White Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “I have non-itchy rashes at the back of my left leg.”
History of Present Illness (HPI): S. K. is a 42-year-old white male who has presented to the clinic complaining of non-itchy rashes at the back of his left leg. The rashes started 2 months ago and have covered a larger area than it was originally. The itchiness is exacerbated by cold weather and reduces during hot weather and when body oil is applied to the affected area. The area looks erythematous and has developed pain due to repeated scratching. The degree of pain that is felt in the area can be estimated as 6/10 on the pain scale.
Medications: S. K. denies using any medications currently.
Allergies: S. K. has reported that he is allergic to Amoxicillin which causes rashes all over his body when used.
Past Medical History (PMH): The patient has never been diagnosed with a serious medical condition before. However, he had a mild headache 6 months ago which was effectively managed using painkillers.
Past Surgical History (PSH): As reported by S. K., he has not undergone a medical operation in the past.
Sexual/Reproductive History: S. K. is married to one wife and they have been blessed with four children: two boys and two girls. He has reported that he is sexually active and denies engaging in extra-marital sex.
Personal/Social History: S. K. consumes neither cigarettes nor alcohol. He is currently working as a casual laborer in a Textile Company nearby.
Immunization History: S. K. received all his scheduled immunizations at the appropriate time as per his medical records.
Health Maintenance/Lifestyle: The patient takes part in a community walk every Saturday to maintain physical fitness. He makes efforts to have three meals a day. He rarely eats fruits because they are not always available in the market but when available, they are always quite expensive.
Significant Family History: S. K. has reported that his father was diagnosed with diabetes 5 years ago and he is using medications to manage his health condition. His mother was diagnosed with hypertension about a year ago. His wife and children have not been diagnosed with any serious medical conditions.
Review of Systems:
General: The patient denies abnormal changes in body weight. He feels fatigued after a whole day’s work.
HEENT: He denies having any physical injury on the head. S. K. has a good vision and denies having any hearing challenges. His sense of smell is good and denies any throat-related problems.
Neck: As reported by S. K., he does not feel any pain around the neck region.
Respiratory: S. K. does not report any challenges with breathing.
Cardiovascular/Peripheral Vascular: He denies chest-related complications such as tightness of the chest.
Gastrointestinal: The patient has denied abdominal problems. He has a good appetite and denies constipation or stomachache.
Genitourinary: S. K. has denied having genital problems. He has not noticed any changes in urine color and urination frequency.
Musculoskeletal: The patient denies joint-related pain. However, he usually feels fatigued after a whole day’s work.
Psychiatric: The patient has denied suffering from psychological problems.
Skin: S. K. reports non-itchy rashes at the back of his left leg.
Hematologic: He denies blood disorders such as anemia and hemophilia.
Endocrine: S. K. does not experience abnormal sweat at night.
Allergic/Immunologic: S. K. is allergic to Amoxicillin. However, he denies being allergic to any food.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Body temperature: 96.8oF, heart rate= 92 beats per minute, BMI: 23.4, Height=52 inches, weight=97.5 lb., respiratory rate=20.
General: S. K. is attentive and properly oriented to time and space. He is well-groomed and dressed neatly. S. K. responds appropriately to questions and maintains eye contact throughout the conversation.
HEENT: The patient’s head has a normal round shape. There are no signs of hair loss/alopecia; S. K.’s eyes are sensitive to changes in light intensity, the conjunctiva is moist; No evidence of a blockage in the ear canal, both ears can respond to sound; The nasal mucosa is hairy and moist with a pink color; No signs of redness in the throat.
Neck: S. K.’s neck is straight and upright. His trachea is positioned midline. The neck region has no swellings.
Lungs: The patient’s lungs have a normal expansion and contraction rhythm. He can inhale and exhale air comfortably.
Heart: No gallop, no heart murmurs.
Abdomen: Auscultation of the abdomen does not produce any bowel sounds. The abdomen lacks an abnormal distention.
Musculoskeletal: No joint pains are felt on touching. S. K. has a normal gain. He can stretch his upper and lower limbs without any problems.
Neurological: Motor or sensory deficits are absent.
Skin: The presence of erythematous and scaly rashes at the back of the patient’s left leg.
Lab tests, x-rays, and other procedures: Complete blood count (CBC), liver function test, and tissue biopsy (Ball et al., 2015; Sullivan, 2019; Dains et al., 2016).
ASSESSMENT:
Differential diagnoses: Psoriasis
: Tinea corporis
: Lyme disease
Primary diagnosis: Psoriasis
The Rationale for Selecting Psoriasis as the Primary Diagnosis
Psoriasis
Psoriasis is a skin condition that is characterized by inflammation. The condition is usually chronic and the skin of the affected persons usually has erythematous and scaly rashes. The rashes developed in psoriasis are usually not itchy. The condition may affect open body surfaces including the legs, arms, neck, and scalp. Symptoms of psoriasis are usually aggravated by cold weather. However, the itchiness and pain usually improve during hot weather (Nair & Badri, 2020). Psoriasis is the most likely diagnosis of patient S.K.’s condition because his symptoms sufficiently match those of the disease.
Tinea Corposis
The other possible diagnosis of S. K.’s condition is tinea corporis. Tinea corporis is a disease condition that may affect people of different age groups. The condition is characterized by erythematous rashes on open areas of the skin such as legs, neck, and arms. Although the condition is characterized by the development of scaly rashes on the skin, these rashes are usually itchy (Yee & Al Aboud, 2021). The rashes on S. K.’s skin are not itchy, a factor that rules out the presence of tinea corporis.
Lyme Disease
Lyme disease is another probable condition for S. K.’s symptoms. People acquire the disease through a tick bite. The affected persons have a localized rash at the site of the bite. The rash is usually erythematous. Lyme disease commonly affects people who interact with animals or who live in bushy areas where ticks are usually found (Fallon & Sotsky, 2017). S. K. does not live in such environments. Besides, his rash is not localized. These factors rule out the presence of Lyme disease.
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.
Fallon, B., & Sotsky, J. (2017). Conquering Lyme Disease: Science bridges the great divide. New York: Columbia University Press.
Nair, P. A., & Badri, T. (2020). Psoriasis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448194/
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia
Yee, G., & Al Aboud, A. M. (2021). Tinea Corporis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544360/