SOAP note: Skin Condition
Instructions
This SOAP note:
Chief Complaint: A 7-year-old male comes in with his father with scaly patches with hair loss on the scalp for 3 weeks.
Definite diagnosis: TINEA CAPTITIS
Differential diagnosis:
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- Tinea capitis
- Impetigo
- Eczema
Solution
Skin Condition
Patient Initials: E. H. Age: 7 years Gender: Male Race: White
Subjective
Chief Complaint (CC): “I have scaly patches with hair loss in my scalp.”
History of Present Illness (HPI): A 7-year-old male has come to the clinic accompanied by his father. The boy has reported that he has scaly patches with hair loss in the scalp. The patches are sometimes itchy. These symptoms have lasted for 3 weeks. As reported by the boy’s father, the affected regions of the scalp become red after scratching.
Past Medical History (PMH): Patient E. H. has never been hospitalized. He had not suffered any serious medical condition that may require hospitalization.
Immunization: E. H.’s medical records indicate that he received his immunizations as scheduled. The diseases for which the client has been vaccinated include; measles, mumps, rubella, influenza, hepatitis B, rotavirus, influenza, and varicella in their correct doses. He is still scheduled to get other immunizations in the coming months.
Allergies: No known drug or food allergies reported.
Medications: None.
Past Surgical History (PSH): Patient E. H. has not been operated for any medical condition.
Family History: E. H.’s paternal grandfather died of stroke 10 years ago. His paternal grandmother is still alive and has not been diagnosed with a serious medical condition. His father is currently 56 years old and has never suffered serious illnesses before. The client’s mother is also well and healthy. He has one older sibling and one younger sibling and both of them are of good health.
Social History: E. H. is the second born in a family of three children. His grandmother, father, and mother are all alive. E. H. is playful and active. His social behavior is appropriate for his age. The current illness has not affected how E. H. interacts and related with his friends and family members in different social settings. He enjoys playing football with his friends.
Review of Systems:
General: No fever, no chills, has a good appetite, and no significant changes in weight reported.
HEENT: No head injury reported. However, the patient reports the presence of scaly patches with alopecia on his scalp. He does not report issues with vision or hearing. E. H. also states that he can breathe properly and does not experience any issues in his throat when swallowing food.
Skin: He denies itchiness and rashes on the skin that covers other parts of the body. However, he reports that he has scaly patches on his head with hair loss on his scalp. The patches are sometimes itchy.
Respiratory: E. H. denies shortness of breath and breathing difficulties. He also denies a cough.
Cardiovascular: Denies chest pain and chest congestions.
Gastrointestinal: Denies stomachache, diarrhea, constipation, or vomiting.
Musculoskeletal: Denies joint-related issues and has not experienced any problems with movement.
Neurologic: E. H. denies headaches or dizziness.
Objective
Vital Signs: Respiratory rate=20, Heart rate=92 bpm, blood pressure=100/73 mm Hg, temperature, 36.3 degree Celsius, BMI=16 kg/m2.
General: E. H. has a bright face and looks healthy. He is neatly dressed and well-groomed. He is attentive and appears ready to respond to questions.
HEENT: The head is normocephalic with no evidence of physical injury. There are scaly patches with alopecia on the scalp. The edges of these patches are erythematous. The ear canal is clear with no evidence of blockage. His eyes are sensitive to changes in light intensity. The mucous membrane of his nasal mucosa appears moist, hairy, and pink. The throat is clear, no lesions, and no erythema.
Skin: The skin on the other parts of the body is moist and smooth. No rashes, no dryness observed.
Chest/Lungs: The left and right lungs are correctly positioned. No wheezing is heard. The patient can comfortable exhale and inhale gases as evidenced by the diaphragm rhythm. No crackles, breath sounds can be heard in all regions of the chest.
Cardiovascular Peripheral/Vascular: Relatively faster heart rate, no murmurs, no gallops or bruits auscultation. Peripheral pulses are present.
Musculoskeletal: No pain in the joints on palpation. The patient can move his joints with ease. No areas of abnormally increased warmth.
Laboratory tests: Fungal culture swab; obtain a scraping from the scalp and examine under a microscope; Use Woods light to check for fluorescence.
Assessment:
Definite diagnosis: Tinea capitis
Differential diagnoses:
- Tinea capitis
- Impetigo
- Eczema
Rationale
Tinea Capitis
Tinea capitis is a common skin infection in children. It is also known as ringworm infection. Most children acquire the condition from their age-mates at school and other social settings. The initial stages of Tinea Capitis appear as a red papule that grows with time. The infection spreads to other areas of the scalp when the original papules are not treated. It may cover the whole scalp. Areas surrounded by the scalp appear inflamed, erythematous, and irritated.
The clinical manifestations of Tinea Capitis include; round scaly patches, itching, redness, and hair loss/alopecia in the affected areas (Al Aboud & Crane, 2020). Patient E. H. presents with all these symptoms and this confirms the presence of Tinea Capitis. The disease might have been transmitted to the patient from another infected child. However, it is important to note that sharing of objects such as hair combs may also increase the chances of tinea transmission from one person to another.
Impetigo
Impetigo is another skin condition that is commonly diagnosed among people of different ages. It is a highly contagious disease just like Tinea Capitis. The two forms of impetigo are non-bullous and bullous impetigo. Impetigo begins from a small vesicle which later raptures and forms either a honey-colored crust in nonbullous form or erythematous skin with a scaly base in the bullous type. Impetigo often affects the skin region in various parts of the body but may also affect the buccal membranes. It rarely occurs on the scalp and is not characterized by alopecia (Freeman, 2020). While some of the features of impetigo are observed on patient E. H., his clinical manifestations do not fully confirm the presence of impetigo.
Eczema
Eczema is a skin condition common in children and that might be one of the possible problems in E. H.’s case. People with eczema have skin rashes that are always itchy. The itchiness influences the affected person to scratch/rub the area. Eczema is also characterized by dry skin that may appear scaly. Redness may occur as a result of constant rubbing or scratching. However, eczema does not form scaly patches, rarely affects the scalp, and is not characterized by hair loss (Nemeth & Evans, 2020). Therefore, the likelihood that the patient has eczema is quite minimal.
Plan
Diagnostics: Performing the right diagnostic tests will enable the clinician to confirm or rule out the presence of Tinea Capitis. Basically, it helps the clinician to make an accurate diagnosis (Dains et al., 2016). The recommended laboratory tests that can be performed to further evaluate the patient include; fungal culture swab, obtaining a scraping from the scalp and examining under a microscope, and using Woods light to check for fluorescence. Tinea Capitis is usually caused by different species of fungi including Microsporum canis, Microsporum audouinii, Microsporum rivalieri, Microsporum ferrugineum, and Trichophyton schoenleinii.
The rationale for performing a fungal culture swab is to confirm the specific fungus involved in the patient’s condition (Al Aboud & Crane, 2020). Observing a scalp scraping under a microscope is intended to reveal the presence of spores and hyphae. Some fungi that cause Tinea Capitis produced fluorescence when observed under Woods light. The Microsporum species will produce a yellow color while will produce a blue color when observed under Woods light (Al Aboud & Crane, 2020). The clinician can perform all these tests to enhance the accuracy of disease diagnosis.
Medications: Administer systemic antifungal medications, specifically 200 mg of griseofulvin taken orally for 4 to 8 weeks. Alternative treatment options are Azole antifungal medications like fluconazole and itraconazole (Al Aboud & Crane, 2020). Systemic steroids can be administered to treat an inflammatory response. Antifungal creams and shampoos can be used together with the medications to limit the disease from spreading to other areas of the scalp (Hay, 2017).
Patient Education: Educate the patient and his father about medication adherence and the importance of maintaining hygiene during treatment. They should be informed about medication side effects and how to manage them (Khosravi et al., 2016). Guidance on how to report adverse drug reactions should be provided.
Health Promotion and Disease Prevention: Maintain hygiene by bathing regularly. The patient should wash the scalp with an antifungal shampoo and apply antifungal cream as he continues with the medication. He should also be advised to avoid sharing hair combs.
Follow-Up Care: Conduct patient follow-up after every four weeks to monitor his progress.
References
Al Aboud, A. M., & Crane, J. S. (2020). Tinea capitis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK536909/
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.
Freeman, M. (2020). Impetigo. BMJ Best Practice. https://bestpractice.bmj.com/topics/en-us/476
Hay, R. J. (2017). Tinea Capitis: Current Status. Mycopathologia 182, 87–93. https://doi.org/10.1007/s11046-016-0058-8
Khosravi, A. R., Shokri, H. & Vahedi, G. (2016). Factors in etiology and predisposition of adult Tinea Capitis and review of published literature. Mycopathologia 181, 371–378 (2016). https://doi.org/10.1007/s11046-016-0004-9
Nemeth, V., & Evans, J. (2020). Eczema. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538209/