Choose one skin condition graphic to document your assignment in the SOAP

Choose one skin condition graphic to document your assignment in the SOAP

Comprehensive SOAP Template

 

Patient Initials: MC  Age: 25 years            Gender: Female

 

 

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

 

Chief Complaint (CC): “Stretch marks.”

 

History of Present Illness (HPI): M.C. is a 25-year-old African American female presenting to the clinic with concerns about having stretch marks on her abdomen. M.C. reports that the stretch marks started appearing when she was around six months pregnant and have been increasing in size and number as the abdomen became larger. The client is a primigravida at 32 weeks gestation with a singleton pregnancy. She denies having any other skin-related symptoms. She conveys concerns that the stretch marks will be permanent and not aesthetically pleasing on her body. The client mentions that she has been using OTC stretch mark creams and applies them about four times a day, but they have not demonstrated any improvement.

 

Medications: OTC stretch mark cream applies four times daily. Iron and Folic Acid supplements one tablet once daily.

Allergies: No known allergies

 

Past Medical History (PMH): History of Anemia at 22 years and had blood transfusion 2 pints. No history of chronic illnesses.

 

Past Surgical History (PSH): No history of surgery.

 

Sexual/Reproductive History: Para 0+0 Gravida 1. Previously had an IUD for two years. Denies history of STIs or gynecologic conditions. No pregnancy-related conditions.

 

Personal/Social History: The client has a history of alcohol consumption but stopped after getting pregnant. She denies smoking or using other drug substances. Her hobbies include cycling and baking. She denies having any difficulties performing ADLs and IADLs. During pregnancy, she exercises by walking at least 3000 steps a day and jogging. She currently takes about five balanced meals a day.

 

Immunization History: Immunization is up to date. Last Flu- March 2022; Has received TT1 and TT2 in this pregnancy.

 

Significant Family History: The client’s parents are alive and well. The younger sister has a history of Asthma. Maternal grandmother has a history of HTN. The Paternal grandfather had DM and died from renal failure at 84 years.

Lifestyle: The patient currently lives with her boyfriend. She has a BA in Drama and Theatre Arts and works as a producer in a production company. She has private health insurance. The client denies observing any cultural practices that may affect her health. Her support system is her boyfriend and sister.

 

Review of Systems:

General: Weight gain of about 18 pounds during pregnancy. Reports increased fatigue. Denies fever, chills, or body weakness.

HEENT: Negative for eye pain, ear discharge, hearing loss, epistaxis, nasal discharge, or sore throat.

Neck: Negative for neck pain/stiffness.

Breasts: Reports increased breast size, nipple size, breast tenderness, and hyperpigmentation of the areola. Denies breast mass or nipple discharge.

            Respiratory: Denies respiratory symptoms.

            Cardiovascular/Peripheral Vascular: Denies respiratory symptoms

            Gastrointestinal: Negative for abdominal distress.

Genitourinary: Reports increased PV discharge. Negative for dysuria, creamy PV discharge, or PV bleeding.

            Musculoskeletal: No limitations in movement.

            Psychiatric: Denies feeling anxious or depressed.

            Neurological: Negative for neurological symptoms.

            Skin: Positive for abdominal stretch marks.

            Hematologic: History of anemia and blood transfusion.

            Endocrine: Negative for excessive thirst, hunger, urination, or sweating.

            Allergic/Immunologic: Denies allergic reactions.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP- 124/74; HR- 76; RR-16; Temp- 98.4; Ht-5’5; Wt- 154 pounds; BMI- 25.6

General: African American female in her mid-20s. She is alert and in no acute distress. Normal gait and posture. Well-groomed, neat, and appropriately dressed. She has appropriate facial expressions, and her affect is appropriate.

HEENT: Head: Normocephalic and atraumatic. Eyes: Sclera is white; Conjunctiva is pink; PERRLA. Ears: TMs are patent, transparent and shiny. Nose: Patent nostrils and nasal septum; No rhinorrhea or epistaxis. Mouth: Pink and moist mucous membranes; Tongue is mid-line, pink, and non-inflamed; No bleeding gums or tooth cavities. Throat: Tonsillar glands are non-erythematous

Neck: Symmetrical neck, Full ROM, Trachea is mid-line, Thyroid gland is normal.

Chest/Lungs: Chest rises and falls uniformly during respiration. Respirations are smooth. Lungs are clear on auscultation bilaterally.

Heart/Peripheral Vascular: No edema or Jugular vein distension; S1 and S2 heard on auscultation. No gallop sounds, bruits, or systole were heard.

Abdomen: Gravid abdomen moves up and down on respiration. No bruits; BS normoactive on all quadrants. No abdominal tenderness, masses, guarding, or organomegaly.

Genital/Rectal: Normal female genitalia. No rectal fissures; Intact sphincter tone

Musculoskeletal:

Neurological: Normal gait and posture; Muscle strength- 5/5; DTRs are intact; CNs II-XII are intact.

Skin: Multiple asymmetric, raised, dark linear streaks on the abdomen. Linea nigra present.

 

ASSESSMENT:

Striae Gravidarum: Striae gravidarum is striae distensae that occur secondary to pregnancy. Striae distensae are characterized by dermal scarring that appears on the skin as violaceous, erythematous, or hypopigmented linear striations (Lokhande & Mysore, 2019). Striae gravidarum presents as linear atrophic scars that typically develop on the abdomen, breasts, hips, and thighs. The visible linear scars develop in dermal damage areas due to excessive skin stretching (Kocaöz et al., 2020). The client has multiple asymmetric, raised, dark linear streaks on the abdomen associated with pregnancy, making Striae gravidarum a priority diagnosis.

Linear focal elastosis: This is characterized by palpable hypertrophic yellow striae rows or linear plaques on the lower back. They are associated with increased abnormal elastic tissues in the lumbosacral area (El-Darouti & Al-Ali, 2019). The patient’s linear plaques make this a differential diagnosis. However, the linear plaques are on the abdomen rather than the lumbosacral area, ruling out Linear focal elastosis as the primary diagnosis.

Anetoderma: This is a rare condition of elastic tissue that manifests with wrinkled and atrophic depressions or saccular skin outpouchings. Individuals have circumscribed areas of flaccid skin that are depressed, elevated, or macular (Genta et al., 2020). This usually occurs on the trunk. Histopathology would be needed to make this diagnosis since it establishes if there is a focal or complete loss of elastic tissue in the dermis.

 

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

 

 

 

References

El-Darouti, M. A., & Al-Ali, F. M. (2019). Challenging Cases in Dermatology Volume 2. doi:10.1007/978-3-030-21855-3

Genta, M. P., Abreu, M. A. M. M., & Nai, G. A. (2020). Anetoderma: an alert for antiphospholipid antibody syndrome. Anais brasileiros de dermatologia, 95(1), 123–125. https://doi.org/10.1016/j.abd.2019.04.010

Kocaöz, S., Gördeles Beşer, N., & Kizilirmak, A. (2020). Striae gravidarum in primigravid women: prevalence, risk factors, prevention interventions, and body image. The Journal of Maternal-Fetal & Neonatal Medicine, 33(23), 3922-3928. https://doi.org/10.1080/14767058.2019.1591363

Lokhande, A. J., & Mysore, V. (2019). Striae Distensae Treatment Review and Update. Indian dermatology online journal, 10(4), 380–395. https://doi.org/10.4103/idoj.IDOJ_336_18