SOAP Note For Assessment And Diagnostic Reasoning Assignment

SOAP Note For Assessment And Diagnostic Reasoning Assignment

SOAP Note

Skin condition image 5#

Patient information

Patient initials: P.T         Age: 58           Race: Hispanic       Gender: male

S.

CC:” Itching and burning rash with blisters.”

HPI:  P.T, a 58-year-old Hispanic male patient, presented to the clinic with a 7-day-old itchy and uncomfortable rash with blisters on his left upper chest and back. He reported that the discomfort, which he rated as a 7/10, is interfering with his regular activities. He reported using Ibuprofen 500mg to relieve discomfort, albeit it has very little effect. He denies having a headache, vomiting, or diarrhea, but claims that the discomfort worsens when it comes into contact with the clothing. SOAP Note For Assessment And Diagnostic Reasoning Assignment

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Medication: ibuprofen 500mg PO prn to manage pain and Glucophage XR PO to manage diabetes

Allergies: no known drug and food allergies

PMH: He has type 1 diabetes, which he is presently managing with Glucophage XR. He also recalled acquiring chicken pox when he was 17 years old.

Immunization: Up to date.  He received his Covid-19 vaccine on 19/7/2021 and influenza vaccine 4/6/2022

Past surgical history: no history was reported.

Family history: His mother (78-year-old): diabetes type 1. Father (deceased): lung cancer. Maternal grandfather (deceased): prostate cancer. His younger sister (35-year-old): hyperlipidemia.  Elder brother (65 years-old): hypertension.

Social history: The patient is a full-time lecturer at a local institution. He is married to a single lady who works as a nurse in a nearby private hospital, and they have four children who attend school far away from home. The patient denies smoking but admits to consuming alcohol once in a while with a companion. He reported enjoying school volleyball on occasion. He is financially secure, and his family’s health is covered by insurance. He stated that he does not use his phone while driving and that he frequently wears his seat belt for safety. Moreover, the patient reported eating a well-balanced diet high in fruits and vegetables.

ROS

General: No fevers, chills, or changes in weight reported.

HEENT: The patient denied any pain, redness, or vision issues. He claims he has no hearing loss, post-nasal drip, or nasal discharge.

Cardiovascular: He denied having chest discomfort, palpitation, an irregular heartbeat, cardiac murmurs, or paroxysmal nocturnal dyspnea.

Respiratory: The patient denies having chronic cough, SOB, and dyspnea on exertion.

GI: He denies vomiting, or experiencing diarrhea. He denies any change in bowel habits or heartburn.

 

GU: The patient denies any urinary hesitancy or dribbling. He denies nocturia and urine frequency. There were no reports of abnormal urethral discharge.

Msk: No myalgias or arthralgias. He reported having no history of trauma or orthopedic injuries.

Neurologic: Denies chronic headaches, seizures, and numbness in lower extremities.

Psychiatric: Denies having depression or anxiety or any suicidal ideation.

Endocrine: Denies heat or cold intolerances

Skin/lymph/heme: reported blisters of painful rashes on the chest and back areas. SOAP Note For Assessment And Diagnostic Reasoning Assignment

O.

PE

VTS: BP 146/68 left arm, sitting using regular adult cuff. Wt.: 72 kg Ht. 5’6 T.: 36.1 RR: 18 P: 78 Sp02: 98%

General: The patient is attentive and oriented x3, well-nourished, and appears to be in no acute distress.

HEENT; normocephalic, EOMI, PERLA, hearing grossly intact, no nasal discharge, the patient teeth and gingiva in good condition.

Cardiovascular: SI and S2 are both normal. There are no murmurs. There were no carotid bruits. The extremities are warm and perfused.

Lungs: Clear to auscultation, rhonchi, no rales noted on percussion.

Skin: There are unilateral dark blood red, fluid-filled vesicles that are slightly warm to the touch on the upper chest and back noted.

Abdomen: Soft and non-distended. Bowel sounds are normoactive.

MSK: ROM intact. Normal gait and posture.

Neuro: Cranial nerve ii to xii intact. Reflexes 2+, no abnormal sensation noted.

Psychiatric: He is oriented to place and time. Good judgement, no abnormal affect noted.

Assessment:

Lab test and result

CBC: results pending

PCR: To detect VZV on skin vesicles lesions.

Tzanck smear

Diagnosis

Differential diagnosis

Herpes zoster

Herpes zoster, also known as shingles, is a viral infection that results in a painful rash. The rash is typically unilateral and appears as a band of blisters on the chest or back (Dosi et al., 2021). The pain of herpes zoster can range from mild to severe, and the rash can scab over a period of 7 days to 10 to several weeks. Transmission is through direct contact with fluid from the rash blisters.

Herpes zoster is associated with a reactivation of the varicella-zoster virus, which is the same virus that causes chickenpox. This reactivation can occur anywhere on the body, but is more common on the chest and back (Kennedy et al., 2018). Hispanic individuals are at a higher risk for developing herpes zoster than other populations, owing to their increased susceptibility to the varicella-zoster virus. Based on the patient’s clinical presentation and the fact that he was once afflicted by chicken at the age of 17, this is the most likely diagnosis for him. SOAP Note For Assessment And Diagnostic Reasoning Assignment

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Herpes simplex virus

HSV is a viral infection characterized by tingling, burning and itching sensation which occurs before emergence of the sore. This infection is also associated with a painful rash that is characterized by the formation of blisters (Sanghera et al., 2018). These blisters can occur on the skin or mucous membranes, and they may be filled with fluid. The blisters are typically found on the lips, mouth, or genitals, and can cause significant discomfort in those affected. In some cases, the blisters can also be found on other parts of the body. The virus is most commonly spread through sexual contact, but can also be spread through close contact with an infected person, such as through shared towels or clothing. Based on the patient’s complaint of a painful rash with blisters, this is a plausible diagnosis; however, the client did not report having tingling and burning feelings a day or two before the rash emerged.

Contact dermatitis

Contact dermatitis is a type of rash that is characterized by the development of blisters. This condition is often associated with pain and can be extremely uncomfortable. In severe cases, the blisters may burst and release a clear fluid. This fluid can then lead to the formation of scabs. Contact dermatitis often affects the hands, feet, and other areas of the body where skin is exposed (Li et al., 2021). It can also occur on the face, neck, and other areas where skin comes into contact with other objects. Contact dermatitis is most often caused by exposure to a substance or object that triggers the inflammation of the skin cells. This can happen when the skin is contaminated by bacteria, fungi, or other substances. The most common sources of contact dermatitis are cosmetics, soaps, detergents, and other irritants (Buckle, 2021). Other causes include exposure to cigarette smoke, ultraviolet light, and chemicals.

Primary diagnoses: Herpes zoster virus

References

Buckley, D. (2021). Generalised Rashes in Adults. In Textbook of Primary Care Dermatology (pp. 161-174). Springer, Cham.

Dosi, T. R., Chawla, A. K., Barkalle, G., & Phulambrikar, T. (2021). Herpes zoster of orofacial region. Journal of Oral and Maxillofacial Pathology: JOMFP, 25(3), 557.

Kennedy, P. G., & Gershon, A. A. (2018). Clinical features of varicella-zoster virus infection. Viruses, 10(11), 609.

Li, Y., & Li, L. (2021). Contact dermatitis: classifications and management. Clinical Reviews in Allergy & Immunology, 61(3), 245-281.

Sanghera, R., & Grewal, P. S. (2019). Dermatological symptom assessment. In Patient Assessment in Clinical Pharmacy (pp. 133-154). Springer, Cham. SOAP Note For Assessment And Diagnostic Reasoning Assignment

For this assignment there is a template attached to use. There is also a document of skin conditions for which you will pick one. 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
• 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. SOAP Note For Assessment And Diagnostic Reasoning Assignment
• 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.

Comprehensive SOAP Exemplar

 Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

 

Patient Initials: _______                 Age: _______                                   Gender: _______

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): Coughing up phlegm and fever

 

History of Present Illness (HPI): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10. SOAP Note For Assessment And Diagnostic Reasoning Assignment

Medications:

• Norvasc 10mg daily
• Combivent 2 puffs every 6 hours as needed
• Advair 500/50 daily
• Singulair 10mg daily
• Over the counter Tylenol 325mg as needed
• Over the counter Benefiber
• Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs – rash

Cipro-headache

 

Past Medical History (PMH):

1.) Asthma

2.) Hypertension

3.) Osteopenia

4.) Allergic rhinitis

5.) Prostate Cancer

Past Surgical History (PSH):

• Cholecystectomy 1994
• Prostatectomy 1986

 

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

He has never smoked

Dipped tobacco for 25 years, no longer dipping

Denied ETOH or illicit drug use.

Immunization History:

Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna

Influenza Vaccination 10/3/2020

PNV 9/18/2018

Tdap 8/22/2017

Shingles 3/22/2016

 

Significant Family History:

One sister – with diabetes, dx at age 65

One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.

 

Lifestyle:

He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.

He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends. SOAP Note For Assessment And Diagnostic Reasoning Assignment

 Review of Systems:

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

HEENT: no changes in vision or hearing; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing. SOAP Note For Assessment And Diagnostic Reasoning Assignment

Neck: Denies pain, injury, or history of disc disease or compression..

Breasts:. Denies history of lesions, masses or rashes.

Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.

CV: denies chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

GI: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.

GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years. SOAP Note For Assessment And Diagnostic Reasoning Assignment

MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.

Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.

Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.

Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.

Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.

OBJECTIVE DATA

 Physical Exam:

Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78 SOAP Note For Assessment And Diagnostic Reasoning Assignment

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyromegally

Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD:  nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: pt declined for this exam

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

Diagnostics/Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Covid PCR-neg

Influenza- neg

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Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Spirometry- FEV1 65%

 Assessment:

 Differential Diagnosis (DDx):

• Asthmatic exacerbation, moderate
• Pulmonary Embolism
• Lung Cancer

 Primary Diagnoses: 

1.) Asthmatic Exacerbation, moderate

 PLAN: [This section is not required for the assignments in this course, but will be required for future courses.] SOAP Note For Assessment And Diagnostic Reasoning Assignment