Skin Comprehensive SOAP Note Discussion

Skin Comprehensive SOAP Note Discussion

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: _______

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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.

 

Medications: Skin Comprehensive SOAP Note Discussion

• 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.

 

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.

 

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. Skin Comprehensive SOAP Note Discussion

 

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.

 

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

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

 

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Diagnostics/Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Covid PCR-neg

Influenza- neg

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.] Skin Comprehensive SOAP Note Discussion

 

Skin Comprehensive SOAP Note

Patient Initials:  A.B_ Age: __42_   Gender: __Male   Race: White American

SUBJECTIVE DATA:

Chief Complaint (CC): “Painful swelling and redness in my left lower leg.”

History of Present Illness (HPI):  Mr. A.B., a 42-year-old White American male, presents to the hospital with a chief complaint of painful swelling and redness in his left lower leg. He reports that the symptoms began two days ago and have progressively worsened. The patient notes that he initially noticed a small red spot on his leg, which has since expanded and become increasingly painful. There is no specific history of trauma or injury to the affected area. The patient describes the pain as a constant throbbing sensation and rates it as 7 out of 10 on the pain scale. He reports difficulty walking due to the swelling and tenderness in the affected leg. The patient has tried over-the-counter pain relievers, but they provided minimal relief.

Medications:

1. Metformin 500 mg orally once daily.
2. Amlodipine 5 mg orally once daily.
3. Hydrochlorothiazide 25 mg orally once daily.

Allergies: No known food or drug allergy

Past Medical History (PMH): He was diagnosed with hypertension in 2020 and had been taking Amlodipine 5 mg orally once daily and Hydrochlorothiazide 25 mg orally once daily as part of his antihypertensive regimen. In addition, he was diagnosed with diabetes two years ago and has been prescribed Metformin 500 mg orally once daily to manage his blood sugar levels.

Past Surgical History (PSH): No surgical history

Sexual/Reproductive History: Mr. A.B. states that he engages in heterosexual intercourse and has never undergone any reproductive procedures or surgeries. He denies any history of sexually transmitted infections (STIs) or known fertility issues. He mentions having two children with his current partner, both conceived naturally. He denies concerns about erectile dysfunction, premature ejaculation, or difficulty achieving orgasm.

Personal/Social History: The patient lives with his wife and two children in a modern apartment equipped with advanced technology in a suburban area with a low crime rate and good public transportation. He is a software engineer working in a sedentary role for a prominent technology company with comprehensive medical insurance. The patient admits to being a former smoker, having quit approximately three years ago when he was diagnosed with hypertension, but does not consume alcohol or recreational drugs.

Health Maintenance: His physical activity is limited due to his desk job, although he mentions occasional leisure activities such as hiking and swimming.

Immunization History: Mr. A.B. is compliant with all immunizations. The last one is the Covid-19 vaccine booster he received in September of last year.

Significant Family History: The family history is notable for hypertension in his father and diabetes in his maternal grandmother. His paternal grandfather succumbed to cellulitis a year ago.

Review of Systems:

General: The patient complains of localized redness, warmth, and swelling in the affected area. He reports feeling fatigued and has a mild fever of 100.4°F (38°C). No recent weight loss or changes in appetite.

HEENT: The patient denies significant head trauma, headache, dizziness, or visual disturbances. He reports no ear pain, tinnitus, or hearing loss. No nasal congestion, sneezing, or sinus pressure. No sore throat, difficulty swallowing, or oral lesions. No dental issues or changes in taste.

Respiratory: The patient denies shortness of breath, cough, wheezing, or chest pain. No history of chronic cough or respiratory infections. No sputum production or blood in the phlegm. No exposure to environmental pollutants or occupational hazards. Skin Comprehensive SOAP Note Discussion

Cardiovascular/Peripheral Vascular: The patient reports no chest pain, palpitations, or irregular heartbeats.

Gastrointestinal: The patient reports no abdominal pain, nausea, vomiting, or changes in bowel movements.

Genitourinary: The patient reports no urinary frequency, urgency, or burning sensation. No hematuria, cloudy urine, or difficulty initiating or stopping urination. No history of kidney stones or urinary tract infections. No erectile dysfunction or changes in libido.

Musculoskeletal: The patient reports pain, tenderness, and swelling in the affected area. No joint pain, stiffness, or limited range of motion. No history of fractures, dislocations, or chronic musculoskeletal conditions. No muscle weakness or abnormal gait.

Neurological: The patient denies any headaches, seizures, or changes in sensation. No numbness, tingling, or weakness in the extremities. No balance or coordination issues. No history of neurological disorders or previous strokes.

Psychiatric: The patient reports no symptoms of depression, anxiety, or mood swings. No changes in sleep patterns or appetite. No history of psychiatric disorders or suicidal thoughts. No difficulty concentrating or memory loss.

Skin/hair/nails: The patient reports no recent skin rashes, itching, or hives. No hair loss or changes in nail color or texture. No history of skin infections or chronic skin conditions.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Blood Pressure: 130/80 mmHg, Heart Rate: 82 beats per minute, Respiratory Rate: 18 breaths per minute, and Temperature: 100.4°F (38°C) (oral).

General: Mr. A.B. appears mildly uncomfortable, favoring his left leg while walking. He is well-groomed and appropriately dressed for the weather. He maintains good eye contact and appears cooperative during the examination.

HEENT: The head is normocephalic and atraumatic. The patient’s eyes are clear and symmetrical, with no signs of redness, discharge, or vision changes. Ears, nose, and throat appear normal without pain, swelling, or discharge.

Neck: Neck is supple with no palpable lymphadenopathy.

Chest/Lungs: Auscultation reveals bilateral breath sounds, with no wheezing or crackles.

Heart/Peripheral Vascular: Heart sounds are regular with no murmurs, rubs, or gallops. Peripheral pulses are palpable and symmetric in all extremities. There are no signs of cyanosis.

Abdomen: There is no tenderness or distension on palpation of the abdomen.

Genital/Rectal: The patient declined this examination.

Musculoskeletal: Mr. A.B. demonstrates a normal gait but slightly limps while walking due to pain in the left leg. There is tenderness to palpation over the anterior aspect of the lower leg, specifically in the area of redness and swelling. Range of motion is limited due to pain, but no deformities or joint effusions are noted.

Neurological: Mr. A.B. is alert and oriented to person, place, and time. Cranial nerves II-XII are intact. The sensation is intact in the affected leg, but he reports increased pain upon movement.

Skin: On inspection, visible erythema (redness) and edema (swelling) were noted in the lower left leg. The affected area appears warm to the touch compared to the surrounding skin. No visible signs of trauma or open wounds are observed.

Diagnostic results:

1. Complete blood count (CBC): leukocytosis and increased neutrophils.
2. Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
3. Positive skin swab culture.

ASSESSMENT:

Differential diagnoses:

1. Deep vein thrombosis (DVT),
2. Erysipelas
3. Contact dermatitis.

Primary Diagnoses

1. Cellulitis

Cellulitis is the most likely diagnosis for the patient. First, the patient presents with localized redness, swelling, and warmth in the affected leg, which are characteristic signs of cellulitis (Brown & Hood Watson, 2022). The symptoms have progressively worsened over the past two days, indicating an acute infection. Additionally, the patient reports constant throbbing pain and tenderness in the affected leg, which are common symptoms of cellulitis.

Secondly, the patient has risk factors that predispose him to cellulitis. Zacay et al. (2021) highlight that his medical history reveals a diagnosis of diabetes, which increases the risk of developing skin infections. Furthermore, the patient’s paternal grandfather had cellulitis, suggesting a potential genetic predisposition. Thirdly, the physical examination findings support the diagnosis of cellulitis. The presence of erythema, edema, warmth in the lower left leg, and tenderness to palpation is consistent with cellulitis (Brown & Hood Watson, 2022). The limited range of motion due to pain also aligns with cellulitis, which can cause discomfort and hinder movement.

Finally, the diagnostic results further support the likelihood of cellulitis. The complete blood count (CBC) shows leukocytosis and increased neutrophils, indicating an inflammatory response to infection. The elevated levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are also indicative of an inflammatory process (Brown & Hood Watson, 2022). The positive skin swab culture confirms the presence of bacteria, which is commonly associated with cellulitis.

While deep vein thrombosis (DVT) is a potential differential diagnosis due to the patient’s leg pain and swelling, the absence of risk factors such as recent immobilization, surgery, or prolonged travel makes it less likely (Waheed & Hotwagner, 2021). Erysipelas is another possibility, but it typically presents with well-demarcated, raised, and intensely red lesions, which are not apparent to the patient (Michael & Shaukat, 2020)Skin Comprehensive SOAP Note Discussion. Contact dermatitis could be considered, but the absence of exposure to potential irritants or allergens makes it less probable compared to cellulitis.

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References

Brown, B. D., & Hood Watson, K. L. (2022, August 8). Cellulitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549770/

Michael, Y., & Shaukat, N. M. (2020). Erysipelas. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532247/

Waheed, S. M., & Hotwagner, D. T. (2021). Deep vein thrombosis (DVT). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507708/

Zacay, G., Hershkowitz Sikron, F., & Heymann, A. D. (2021). Glycemic control and risk of cellulitis. Diabetes Care, 44(2), 367–372. https://doi.org/10.2337/dc19-1393 Skin Comprehensive SOAP Note Discussion

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.

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.

For the skin condition I choose the cellulitis from the pictures (diagram #4) Week_4_NURS_6512_Week04_skinConditions.doc