Skin Comprehensive SOAP Note Discussion

Skin Comprehensive SOAP Note Discussion

Week 4

Skin Comprehensive SOAP Note

Patient Initials: TM     Age: 38           Gender: M                   Ethnicity: Caucasian

SUBJECTIVE DATA:

Chief Complaint (CC): The client is a 38-year-old Caucasian man who has fever, erythema, edema, tenderness, and heat in his right lower limb near the knee. This comes 4 days after he was unintentionally cut while pruning his garden (The image chosen is image number 4).

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History of Present Illness (HPI): The patient came with the above-mentioned inflammatory characteristics. He denied any prior knowledge of having suffered the same. He claims he became aware of the signs 4 days after getting a cut on his right lower extremity. The sore is typically unpleasantly sore and heated to the hand. He also claims to have a temperature. The soreness is momentarily relieved by analgesic and anti-inflammatory drugs such as Tylenol, but it is exacerbated by movement. The soreness, heat, and pain are constant. He assigns a severity rating of 8/10 to his complaints Skin Comprehensive SOAP Note Discussion.

Medications: OTC Tylenol 500 mg prn for the pain; glibenclamide (Glyburide) and metformin for the diabetes that he has.

Allergies: He does not have any allergies as far as he can recall.

Past Medical History (PMH): He has pre-existing type II diabetes mellitus on glibenclamide and metformin.

Past Surgical History (PSH): There is no significant surgical history.

Sexual/Reproductive History: He describes himself as a male heterosexual, is married and has two children.

Personal/Social History: Patient TM is a high school teacher who lives in a relatively middle class neighborhood with good amenities. He stays with his family of four and only occasionally goes out on weekends with friends. His hobbies include nature walks, gardening, and fishing.

Health Maintenance: He usually keeps appointments for ENT, ophthalmic, and dental check-ups every six months with his whole family.

Immunization History: He had all of his vaccines as a child. He has also obtained booster Tdp doses as an adult, as well as pneumonia and flu vaccines. Following the outbreak of the pandemic, he also received two doses of Covid-19. Two months ago he again got a booster injection of the Covid-19 vaccine.

Significant Family History: The mother suffers from high blood pressure while his father is a long time type II diabetic managed on diet and exercise alone.

Review of Systems (ROS): Skin Comprehensive SOAP Note Discussion

GENERAL: Positive for a temperature (fever) but denies lethargy and losing weight.

HEENT: Diplopia, sensitivity to light, otorrhea, ringing, runny nose, and hoarseness are all denied.

Respiratory: Denies breathing problems or coughing.

Cardiovascular/Peripheral Vascular: Denies chest pains, tightness, or edema.

Gastrointestinal Tract (GIT): Negative for diarrhea, vomiting, or nausea. She states that she has regular bowel movements.

Genitourinary: Negative for dysuria, frequency, hesitancy, and loss of bladder control.

Musculoskeletal: Negative for joint and back pains as well as muscle pain (myalgia).

Neurological: He is negative for paraesthesia, tremors, dizziness, seizures, syncope, or paresis.

Psychiatric: Negative for anxiety and depression.

Skin/hair/nails: Negative for rashes, eczema, or itching. Positive for all the signs of inflammation on the right shin (Ball et al., 2019)Skin Comprehensive SOAP Note Discussion.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 130/75 regular cuff and sitting; P 72, regular; T 99.8°F; RR 16, non-labored; BMI 27.6 kg/m² (overweight)

General: The patient is aware and aware of his or her surroundings, including location, persons, place, moment, and occurrence. He speaks in a clear and purposeful manner. His cleanliness is suitable for the time of day and climate.

HEENT: The pupils are equal, circular, and light and accommodation responsive (PERRLA). The extraocular muscles are not damaged (EOMI). The nasal turbinates are not inflamed, and the tympanic membranes have a satisfactory light reflex on both sides. There is no erythema on the throat.

Neck: The neck is supple with no cervical lymphadenopathy.

Chest/Lungs: Clear lung fields bilaterally with no crepitations, rales, wheezing, rhonchi, or coughing.

Heart/Peripheral Vascular: S 1 and S2 audible and RRR with no murmur or bruit.

Skin: The whole anterior portion of the right lower limb is inflamed, heated to the touch, reddish, and tender to touch.

Diagnostic results:

• WBC 14.8 x 10⁹ with significant leucocytosis
• CRP 10 mg/L which is quite high
• Hb 13.2 g/dL which is within normal range for male (Hammer & McPhee, 2018)Skin Comprehensive SOAP Note Discussion.

ASSESSMENT:

After patient TM had been evaluated as shown above, three differential diagnoses come to mind. They are cellulitis, thrombophlebitis and contact dermatitis (Hammer & McPhee, 2018).

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1. Cellulitis

The skin condition known as cellulitis is a serious infection that is caused by a skin breach, most usually encountered in the lower extremities. The bacteria or microorganisms that cause this condition are usually found in the microbiota of the skin. In other words, these are the normal skin flora that surrounds a cut or a breach in the skin (Hammer & McPhee, 2018)Skin Comprehensive SOAP Note Discussion. Cellulitis is caused by any condition that impairs skin integrity or decreases immunity. Among them are obesity, diabetes, and old age (Cranendonk et al., 2017). The most common causes of cellulitis in these settings are streptococci and staphylococci. According to Katzung (2018), m Methicillin-resistant Staphylococcus aureus (MRSA) is gaining prominence as a leading cause of cellulitis, providing major antibiotic treatment challenges.

2. Thrombophlebitis

The condition known as thrombophlebitis is an inflammatory illness in which a thrombus develops and plugs one or more deep veins, usually in the legs. The injured vein could be close to the skin’s surface, resulting in superficial thrombophlebitis, or it could be deep within a muscle, resulting in deep vein thrombosis, or DVT (Hammer & McPhee, 2018). Trauma, like in the case of patient TM, surgery, and prolonged immobilization are all causes of thrombophlebitis.

3. Contact Dermatitis

Contact dermatitis is a form of response or eczema produced by an allergic reaction to a chemical. It causes inflammation in the injured region and might be difficult to differentiate from cellulitis (Hammer & McPhee, 2018)Skin Comprehensive SOAP Note Discussion. In this scenario, the only thing that aids in the right diagnosis of cellulitis is a positive history of unintentional trauma.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Cranendonk, D.R., Lavrijsen, A.P.M., Prins, J.M., & Wiersinga, W.J. (2017). Cellulitis: Current insights into pathophysiology and clinical management. The Netherlands Journal of Medicine, 75(9), 366-378. https://www.njmonline.nl/getpdf.php?id=1907

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14^th ed. McGraw-Hill Education.

Week 4

Skin Comprehensive SOAP Note

Patient Initials: TM     Age: 38           Gender: M                   Ethnicity: Caucasian

SUBJECTIVE DATA:

Chief Complaint (CC): The client is a 38-year-old Caucasian man who has fever, erythema, edema, tenderness, and heat in his right lower limb near the knee. This comes 4 days after he was unintentionally cut while pruning his garden (The image chosen is image number 4)Skin Comprehensive SOAP Note Discussion.

History of Present Illness (HPI): The patient came with the above-mentioned inflammatory characteristics. He denied any prior knowledge of having suffered the same. He claims he became aware of the signs 4 days after getting a cut on his right lower extremity. The sore is typically unpleasantly sore and heated to the hand. He also claims to have a temperature. The soreness is momentarily relieved by analgesic and anti-inflammatory drugs such as Tylenol, but it is exacerbated by movement. The soreness, heat, and pain are constant. He assigns a severity rating of 8/10 to his complaints.

Medications: OTC Tylenol 500 mg prn for the pain; glibenclamide (Glyburide) and metformin for the diabetes that he has.

Allergies: He does not have any allergies as far as he can recall.

Past Medical History (PMH): He has pre-existing type II diabetes mellitus on glibenclamide and metformin.

Past Surgical History (PSH): There is no significant surgical history.

Sexual/Reproductive History: He describes himself as a male heterosexual, is married and has two children.

Personal/Social History: Patient TM is a high school teacher who lives in a relatively middle class neighborhood with good amenities. He stays with his family of four and only occasionally goes out on weekends with friends. His hobbies include nature walks, gardening, and fishing.

Health Maintenance: He usually keeps appointments for ENT, ophthalmic, and dental check-ups every six months with his whole family.

Immunization History: He had all of his vaccines as a child. He has also obtained booster Tdp doses as an adult, as well as pneumonia and flu vaccines. Following the outbreak of the pandemic, he also received two doses of Covid-19. Two months ago he again got a booster injection of the Covid-19 vaccine Skin Comprehensive SOAP Note Discussion.

Significant Family History: The mother suffers from high blood pressure while his father is a long time type II diabetic managed on diet and exercise alone.

Review of Systems (ROS):

GENERAL: Positive for a temperature (fever) but denies lethargy and losing weight.

HEENT: Diplopia, sensitivity to light, otorrhea, ringing, runny nose, and hoarseness are all denied.

Respiratory: Denies breathing problems or coughing.

Cardiovascular/Peripheral Vascular: Denies chest pains, tightness, or edema.

Gastrointestinal Tract (GIT): Negative for diarrhea, vomiting, or nausea. She states that she has regular bowel movements.

Genitourinary: Negative for dysuria, frequency, hesitancy, and loss of bladder control.

Musculoskeletal: Negative for joint and back pains as well as muscle pain (myalgia)Skin Comprehensive SOAP Note Discussion.

Neurological: He is negative for paraesthesia, tremors, dizziness, seizures, syncope, or paresis.

Psychiatric: Negative for anxiety and depression.

Skin/hair/nails: Negative for rashes, eczema, or itching. Positive for all the signs of inflammation on the right shin (Ball et al., 2019).

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 130/75 regular cuff and sitting; P 72, regular; T 99.8°F; RR 16, non-labored; BMI 27.6 kg/m² (overweight)

General: The patient is aware and aware of his or her surroundings, including location, persons, place, moment, and occurrence. He speaks in a clear and purposeful manner. His cleanliness is suitable for the time of day and climate.

HEENT: The pupils are equal, circular, and light and accommodation responsive (PERRLA). The extraocular muscles are not damaged (EOMI). The nasal turbinates are not inflamed, and the tympanic membranes have a satisfactory light reflex on both sides. There is no erythema on the throat. Skin Comprehensive SOAP Note Discussion

Neck: The neck is supple with no cervical lymphadenopathy.

Chest/Lungs: Clear lung fields bilaterally with no crepitations, rales, wheezing, rhonchi, or coughing.

Heart/Peripheral Vascular: S 1 and S2 audible and RRR with no murmur or bruit.

Skin: The whole anterior portion of the right lower limb is inflamed, heated to the touch, reddish, and tender to touch.

Diagnostic results:

• WBC 14.8 x 10⁹ with significant leucocytosis
• CRP 10 mg/L which is quite high
• Hb 13.2 g/dL which is within normal range for male (Hammer & McPhee, 2018).

ASSESSMENT:

After patient TM had been evaluated as shown above, three differential diagnoses come to mind. They are cellulitis, thrombophlebitis and contact dermatitis (Hammer & McPhee, 2018).

1. Cellulitis

The skin condition known as cellulitis is a serious infection that is caused by a skin breach, most usually encountered in the lower extremities. The bacteria or microorganisms that cause this condition are usually found in the microbiota of the skin. In other words, these are the normal skin flora that surrounds a cut or a breach in the skin (Hammer & McPhee, 2018)Skin Comprehensive SOAP Note Discussion. Cellulitis is caused by any condition that impairs skin integrity or decreases immunity. Among them are obesity, diabetes, and old age (Cranendonk et al., 2017). The most common causes of cellulitis in these settings are streptococci and staphylococci. According to Katzung (2018), m Methicillin-resistant Staphylococcus aureus (MRSA) is gaining prominence as a leading cause of cellulitis, providing major antibiotic treatment challenges.

2. Thrombophlebitis

The condition known as thrombophlebitis is an inflammatory illness in which a thrombus develops and plugs one or more deep veins, usually in the legs. The injured vein could be close to the skin’s surface, resulting in superficial thrombophlebitis, or it could be deep within a muscle, resulting in deep vein thrombosis, or DVT (Hammer & McPhee, 2018). Trauma, like in the case of patient TM, surgery, and prolonged immobilization are all causes of thrombophlebitis.

3. Contact Dermatitis

Contact dermatitis is a form of response or eczema produced by an allergic reaction to a chemical. It causes inflammation in the injured region and might be difficult to differentiate from cellulitis (Hammer & McPhee, 2018)Skin Comprehensive SOAP Note Discussion. In this scenario, the only thing that aids in the right diagnosis of cellulitis is a positive history of unintentional trauma.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Cranendonk, D.R., Lavrijsen, A.P.M., Prins, J.M., & Wiersinga, W.J. (2017). Cellulitis: Current insights into pathophysiology and clinical management. The Netherlands Journal of Medicine, 75(9), 366-378. https://www.njmonline.nl/getpdf.php?id=1907

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14^th ed. McGraw-Hill Education.

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.

To Prepare Skin Comprehensive SOAP Note Discussion
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.
The 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.

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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 three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources. Skin Comprehensive SOAP Note Discussion