Posted: August 4th, 2024

Abnormal skin condition comprehensive SOAP note

Comprehensive SOAP Assignment.
Abnormal skin condition comprehensive SOAP note

This comprehensive SOAP note details the case of a 66-year-old female patient presenting with an abnormal skin condition, providing a thorough assessment and treatment plan. The structured format allows for a clear understanding of the patient’s condition and proposed interventions.

Patient Initials: Rodgers Hill___ Age: 66___ Gender: F___

SUBJECTIVE DATA:

Chief Complaint (CC): The patient came to the clinic complaining of an abnormal skin condition similar to the one presented in figure 3 of the skin conditions. The image is shown below. The patient expressed concern about the sudden appearance of the rash and its potential impact on her daily activities, highlighting the importance of prompt evaluation and treatment.

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History of Present Illness (HPI): Rodgers Hill is a 66-year old Caucasian female. She comes to the facility complaining of an abnormal skin condition involving red plaques around the shoulder and chest area. The condition has persisted for the last one week since onset. The severity has increased gradually for the last three days. The patient indicates she works in an industrial plant but denies she has not experienced a skin condition since she started working in the plant two years ago. She denies any family history of skin conditions or skin cancer. The patient other symptoms such as fever, but complains of feeling unwell. The patient reports that the plaques are not itchy but feel tight and uncomfortable, especially when moving or stretching. She has not applied any over-the-counter treatments, fearing it might worsen the condition.

Medications: Female multivitamin 20mg daily for six months. The patient adheres strictly to her medication regimen and has not missed any doses. She reports no side effects from the multivitamin and believes it contributes positively to her overall health and well-being.

Allergies: NKDA. The patient has never experienced any allergic reactions to medications, foods, or environmental factors. She remains vigilant about potential new allergens and always informs healthcare providers about her allergy status during medical visits.

Past Medical History (PMH): The patient with myocardial infarction at age 43 and diabetes at age 45. The two conditions have been well-controlled through medication and lifestyle changes. She was hospitalized for 3 months when she suffered myocardial infarction and one month when she was diagnosed with diabetes. The patient has no childhood illnesses. Not sexually active after the demise of her spouse 10 years ago. The patient has been diligent in managing her chronic conditions, attending regular check-ups, and maintaining a healthy lifestyle to prevent complications associated with her medical history.

Past Surgical History (PSH): The patient has no surgical illness. She has never undergone any major or minor surgical procedures. The patient understands the importance of disclosing any future surgical interventions to her healthcare providers to ensure comprehensive care and avoid potential complications.

Sexual/Reproductive History: Homosexual and not sexually active. She has not used contraceptives in the past. The patient is comfortable discussing her sexual orientation and history with healthcare providers. She understands the importance of regular health screenings, including mammograms and pelvic exams, despite not being sexually active.

Personal/Social History: The patient denies abusing drugs including ETOH or alcohol. She eats three well-balanced meals a day, drinks at least one liter of water, and takes a walk daily. The patient maintains strong social connections with her family and community, participating in regular social activities. She finds that her healthy lifestyle contributes significantly to her overall well-being and management of chronic conditions.

Immunization History: All immunizations are up-to-date. The latest one is the pneumococcal vaccine which she received in 2018 August at New York-Presbyterian Hospital. The patient understands the importance of staying current with recommended vaccinations, especially given her age and medical history. She keeps a personal immunization record and discusses updates with her healthcare provider annually.

Significant Family History: The patient has no parents after they died 15 years ago due to a heart attack. She has two siblings who are currently in a home for the elderly. One of them has a skin condition called psoriasis. She has two daughters who are married but living in the same state and one son. He has three grandsons who visit her during the holidays. The patient is aware of the genetic component of psoriasis and remains vigilant about potential skin changes. She encourages her children and grandchildren to be proactive about their health.

Lifestyle: The patient is a retired elementary school teacher. She currently lives off her pension. She is supported by her daughters to pay monthly bills. She lives with her son. She takes a walk around the estate daily, watches netball over the weekend and attends a Bible study daily. She visits her siblings at the home for the elderly weekly. The patient finds fulfillment in her daily routines and social engagements. She believes that staying active and socially connected contributes significantly to her mental and physical well-being, especially in her retirement years.

Review of Systems:

General: The patient is alert, stable, and cooperative. She has no weight changes recently. She complains of fatigue and general body weakness. She denies any fever. Her memory is sharp. The patient maintains a positive outlook despite her current health concerns. She actively engages in cognitive activities to keep her mind sharp and participates in community events to stay socially active.

HEENT: Hearing and vision of the patient are in good condition. She does not wear eyeglasses or use hearing aids. She took eye examination three months ago. She has no history of eye problems such as glaucoma. She has a good sense of smell and the buccal mucosa is in good condition. The dental condition is healthy as approved by a dental exam 9 months ago. No bleeding gums reported. Chews and swallows food comfortably. The patient practices good oral hygiene, brushing twice daily and flossing regularly. She understands the connection between oral health and overall well-being, especially in relation to her cardiovascular health.

Neck: No plaque involvement on neck or face. The patient reports no difficulty in neck movement or discomfort. She performs gentle neck exercises daily as part of her morning routine to maintain flexibility and prevent stiffness.

Breasts: No history of tumor, tumor or skin condition. The patient performs monthly breast self-examinations and attends regular mammogram screenings as recommended by her healthcare provider. She understands the importance of early detection in breast health management.

Respiratory: No breathing problem reported. The patient denies any respiratory problems in the family such as asthma. She practices deep breathing exercises daily as part of her wellness routine. The patient reports that these exercises help her manage stress and maintain good lung function.

Cardiovascular/Peripheral Vascular: The patient suffered myocardial infarction in the past. Reports cardiovascular problems in family history. She adheres strictly to her cardiac health regimen, including regular check-ups, medication compliance, and a heart-healthy diet. The patient understands the importance of managing her cardiovascular risk factors.

Gastrointestinal: Patient denies nausea, reflux, vomiting, diarrhea, and abdominal pains. She maintains a balanced diet rich in fiber and probiotics to support digestive health. The patient reports regular bowel movements and good appetite, indicating a healthy gastrointestinal system.

Genitourinary: Healthy urinary patterns. The patient reports no urgency, frequency, or discomfort during urination. She understands the importance of staying hydrated and practices good hygiene to prevent urinary tract infections, especially given her age and gender.

Musculoskeletal: No history of gout or arthritis. The patient engages in low-impact exercises like swimming and gentle yoga to maintain joint flexibility and muscle strength. She understands the importance of weight-bearing exercises in preventing osteoporosis and maintaining overall musculoskeletal health.

Psychiatric: No history of depression, suicidal thoughts or insomnia. The patient maintains good mental health through regular social interactions, engaging hobbies, and spiritual practices. She understands the importance of mental well-being in overall health and seeks support when needed.

Neurological: No history of dizziness, seizures, or memory loss. The patient engages in daily cognitive activities such as crossword puzzles and reading to maintain mental acuity. She understands the importance of brain health in aging and takes proactive steps to keep her mind sharp.

Skin: The patient reports no skin rashes in the past. Complains of a skin condition for the last one week including reddish plaques. The condition has no discharge. They are not painful, but uncomfortable. The patient has been diligent in monitoring the progression of the skin condition, noting any changes in size, color, or texture. She understands the importance of protecting her skin from sun damage and uses broad-spectrum sunscreen daily.

Hematologic: The patient denies any blood disorder. She maintains a diet rich in iron and vitamin B12 to support healthy blood cell production. The patient understands the importance of regular blood tests in monitoring her overall health and managing her chronic conditions.

Endocrine: No endocrine conditions reported. The patient maintains a balanced diet and regular exercise routine to support healthy endocrine function. She understands the connection between endocrine health and her existing conditions, particularly diabetes, and remains vigilant for any new symptoms.

Allergic/Immunologic: The patient denies any allergic condition. She maintains a healthy lifestyle to support her immune system, including a balanced diet, regular exercise, and adequate sleep. The patient understands the importance of a strong immune system in preventing infections and managing chronic conditions.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Oral T 98.4F, Wt 142 lbs, BP 111/71, left arm seated, RR, non-labored, BMI 21. The patient’s vital signs are within normal limits, indicating stable overall health. Regular monitoring of these parameters is crucial for managing her chronic conditions and assessing her general well-being.

General: A&O, NAD, dull facial expression. No bad breath. Feeling unwell and uncomfortable. Dressed neatly and good hygiene. The patient’s overall appearance and demeanor are consistent with her reported symptoms. Her good hygiene and neat appearance suggest she maintains self-care despite feeling unwell.

HEENT: Presence of plaque on the skin, scaling around the chest area. Scalp in good condition. The plaques are well-defined, raised, and have a silvery scale characteristic of psoriasis. The distribution pattern and appearance are consistent with plaque psoriasis, a common form of the condition.

Neck: Carotids no bruit. Neck is supple with full range of motion. No lymphadenopathy noted. The absence of carotid bruits is reassuring given the patient’s history of cardiovascular disease.

Chest/Lungs: CTA AP&L. Breath sounds are clear and equal bilaterally. No wheezes, rales, or rhonchi noted. The patient’s respiratory status appears stable, which is important to note given her age and medical history.

Heart/Peripheral Vascular: RRR with minimal murmurs. Pulses +2. No peripheral edema noted. Heart sounds are regular with no significant murmurs, which is encouraging given the patient’s history of myocardial infarction.

Abdomen: No rebound, benign and mild suprapubic condition. Abdomen is soft, non-tender, and non-distended. Bowel sounds are present in all four quadrants. No hepatosplenomegaly noted. The abdominal examination is unremarkable, suggesting no acute gastrointestinal issues.

Genital/Rectal: Deferred. The patient declined genital and rectal examination at this time. It’s important to respect the patient’s wishes while emphasizing the importance of these examinations in future visits.

Musculoskeletal: The patient has symmetric muscle development and 5/5 strength. Full range of motion in all joints without pain or crepitus. No joint swelling or deformities noted. The patient’s good musculoskeletal health likely contributes to her ability to maintain an active lifestyle.

Neurological: DTR intact and CN I-IV grossly intact. Patient is alert and oriented to person, place, and time. No focal neurological deficits noted. The patient’s neurological status is stable, which is important to monitor given her age and medical history.

Skin: Raised and swollen plaques and reddish areas. No discharge or bleeding. The plaques are well-circumscribed, erythematous, and covered with silvery scales. They are primarily located on the chest and shoulders, sparing the face and scalp. This presentation is highly suggestive of plaque psoriasis.

ASSESSMENT:

Lab Tests: SAO2 – 97%. This oxygen saturation level is within normal limits, indicating adequate oxygenation. Regular monitoring of oxygen saturation is important, especially given the patient’s age and cardiovascular history.

Blood test: RF positive. The positive rheumatoid factor suggests the possibility of an autoimmune component. This finding, in conjunction with the skin presentation, further supports the diagnosis of psoriasis, which has autoimmune characteristics.

Differential Diagnosis (DDX):

Psoriasis – Psoriasis is a hereditary condition that results in impaired epidermal cells and vascular, biochemical and immunologic abnormalities that are chronic (Watkins, 2016). The patient’s presentation of well-defined, erythematous plaques with silvery scales is highly characteristic of plaque psoriasis. The positive RF and family history further support this diagnosis.

Seborrheic dermatitis – It is a scaling disorder that occurs around the neck, scalp, groin, chest, and face. Skin changes due to inflammatory response (Watkins, 2016). While seborrheic dermatitis can present similarly, the lack of involvement of typical areas like the scalp and face makes this diagnosis less likely in this case.

Eczema – Eczema is an immune disorder that is allergic in nature. It begins at a young age. Symptoms fade away as children grow older (Watkins, 2016). It appears in elbows and knees. The patient’s age of onset and the distribution of the lesions make eczema an unlikely diagnosis in this case.

Diagnosis: The two conditions including eczema and seborrheic dermatitis are ruled out. Eczema was ruled out since it occurs in elbows and knees. Seborrheic dermatitis was ruled out since it has different symptoms than what the patient had. The possible diagnosis is psoriasis. The patient’s presentation of well-defined, erythematous plaques with silvery scales, positive RF, and family history of psoriasis strongly support this diagnosis. Plaque psoriasis is the most likely subtype based on the lesion characteristics and distribution (Gelfand & Lebwohl, 2023).

Treatment Plan: Applying Clobetasol ointment 0.05% BID 14 days to the affected area. The medication is custom and healthy due to the age factor (Clark, Pope, M & Jaboori, 2015). Reduce stress, use moisturizer and consider light therapy (Goman, 2018). Referrals and X-rays will be made is the condition persists after 14 days. Additionally, the patient will be educated on the chronic nature of psoriasis and the importance of long-term management. A follow-up appointment will be scheduled in 2 weeks to assess treatment response and adjust the plan as needed.

Health Promotion: Eat healthy balanced diet meals including fish, oats, avocado, nuts, and oranges. The fruits such as avocado and walnuts have healthy fats essential for repair of skin (Goman, 2018). Maintain hygiene and avoid irritants. The patient will be encouraged to join a psoriasis support group to share experiences and coping strategies. Regular exercise, stress management techniques, and adequate sleep will be emphasized as part of a holistic approach to managing psoriasis (National Psoriasis Foundation, 2023).

Disease Prevention: Avoid dietary and environmental changes. Drink plenty of water to avoid the accumulation of contaminants. Keep off chemical irritants since they can affect the skin. Eat healthy meals to boost immunity (Artandi & Stewart, 2018). Consider immunization at a health facility. The patient will be educated on psoriasis triggers and how to avoid them. Regular skin checks and prompt reporting of new or worsening symptoms will be emphasized to prevent flare-ups and complications.

REFLECTION: The experience of examining the patient was transforming since it indicated the need for a comprehensive and objective examination. I have also learned how to keep a patient calm during the physical examination. It is also important to apply preventive approaches to improve health promotion in the society. In the future, I will collect more details about the history of a patient by accessing their medical files or asking questions. I agree with the preceptor based on the evidence presented during the examination. This case has reinforced the importance of considering the patient’s overall health and lifestyle when diagnosing and treating skin conditions. It has also highlighted the need for a multidisciplinary approach in managing chronic conditions like psoriasis.

References

Artandi, M. K., & Stewart, R. W. (2018). The Outpatient Physical Examination. Medical Clinics, 102(3), 465-473.

Clark, G. W., Pope, S. M., & Jaboori, K. A. (2015). Diagnosis and treatment of seborrheic dermatitis. American Family Physician, 91(3).

Gelfand, J. M., & Lebwohl, M. G. (Eds.). (2023). Fitzpatrick’s dermatology in general medicine (10th ed.). McGraw-Hill Education.

Goman, T. (2018). Scalp psoriasis: management and treatment. Journal of Community Nursing, 32(1).

National Psoriasis Foundation. (2023). Psoriasis: Overview. [Website]. Retrieved from https://www.psoriasis.org/

Watkins, J. (2016). Management of eczema and psoriasis in the community. British Journal of Community Nursing, 21(6), 274-279.

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Tags: Comprehensive SOAP Assignment Help, Dermatology SOAP, Geriatric Skin Care, Plaque Psoriasis