Sample Answer for NURS 6512 Skin Assessment SOAP notes Included After Question
SUBJECTIVE DATA:
“I have multiple red raised lesions all over my chest and stomach”. This happened about two weeks ago
Chief Complaint (CC): Multiple raised red spots all over torso (image #2).
History of Present Illness (HPI): A 65-year-old Caucasian male presents to the clinic with multiple red papule all over torso. The spots are red in color, some raised and some are flat to the skin. There are about 48 spots and they look like little cherries and have rough and smooth edges to it. It started about two weeks ago with 5 spots and gradually increased to about 48 spots. There are no relieving or aggravating factors.
You must include the 7 attributes of each principal symptom:
- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
Medications: None
Allergies: NKA
Past Medical History (PMH): None
Past Surgical History (PSH): None
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Use alcohol occasionally. Sedentary lifestyle
Immunization History: pneumonia vaccine 10/2019
Significant Family History: mother has a hx of diabetes and father has a hx of hypertension
Lifestyle: Retired and receiving unemployment checks
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Red raised and slightly elevated lesion with distinct edges, about 48 lesions on torso.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin: Multiple red raised skin lesions scattered all over torso approximately 48 lesions, round in shape and some flat to the skin with distinct edges in varying sizes are about 0.5-1mm. no exudates or bleeding noted.
A Sample Answer For the Assignment: NURS 6512 Skin Assessment SOAP notes
Title: NURS 6512 Skin Assessment SOAP notes
A cherry angioma is a small papular angioma. It is also called a senile angioma. (Oakley, 2017). They occur in virtually everyone older than 30 years and increase numerically with age (Ball et al., 2018). Cherry angiomas are not usually painful and spread everywhere on the body. “In their early, and smaller, stages they are typically maraschino cherry red, hence the name cherry angiomas. As they enlarge or become thrombosed, some lesions become darker red or even black in color” (MDedge Family Medicine, 2019). “Cherry angiomas do not require treatment. If treatment is desired for cosmetic purposes, they can be treated with electrocautery, cryosurgery, or laser” (MDedge Family Medicine, 2019).
“Angiokeratoma is a benign skin lesion, appearing more commonly in older individuals. Angiokeratomas can be described as wart-like, red to black papules. Angiokeratomas vary in color, size, and shape; however, they are usually dark red to black in color. They range in size from papule lesions (up to 5 millimeters in size) to small plaque lesions (6 millimeters or higher in size). When touched, angiokeratomas feel hard and cannot be blanched, or faded, by compressing them. They may have an uneven surface described as “pebbled” (aocd.org, n.d.).
It is most definitely not a pyogenic granuloma because “Pyogenic granuloma is a relatively common skin growth. It is usually a small red, oozing and bleeding bump that looks like raw hamburger meat. It often seems to follows a minor injury and grows rapidly over a period of a few weeks to an average size of a half an inch.” (aocd.org, n.d.).
“Nodular basal cell carcinoma comprises about 60-80% of the cases and occurs most often on the skin of the head. Clinically it is presented by elevated, exophytic pearl-shaped nodules with telangiectasie on the surface and periphery” (Dourmishev, Rusinova, & Botev, 2013). Knowing this, it is very obvious this is not the diagnosis for this patient. “The lesions with big sizes and the central necrosis are defined as ulcus rodens” (Dourmishev et al., 2013).
List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses
A Sample Answer 2 For the Assignment: NURS 6512 Skin Assessment SOAP notes
Title: NURS 6512 Skin Assessment SOAP notes
SUBJECTIVE DATA:
Chief Complaint (CC): Image __: Cellulitis of the leg.
History of Present Illness (HPI): T.N is a 54-year-old Caucasian male patient who presented to the clinic complaining that her left leg is red, tender, and swollen. Additional symptoms include worsening erythema and warmth. The patient reports that these symptoms started about 3 days before the present visit after hitting his leg while washing his car near the garage. He claims that the pain was mild at first but has been worsening ever since. He has tried to use ice blocks which seems to be helpful. He has also been taking Tylenol and Ibuprofen for management of the pain and swelling. He however claims that they only help for a while, but the condition worsens when the drugs wear out of the system.
Medications:
- Ibuprofen 400mg is taken after every 4 to 6 hours for management of the pain.
- Tylenol 650mg PO after every 4 to 6 hours for management of the pain.
- Albuterol Inhaler 2 puffs PRN.
Allergies:
Seasonal allergy reported
No known drug or food allergies reported
Past Medical History (PMH):Diagnosed with asthma at the age of 16 years, which is well controlled with an albuterol inhaler.
Past Surgical History (PSH): Denies any history of hospitalization or undergoing any surgical procedure.
Sexual/Reproductive History:Heterosexual. Married with two kids.
Personal/Social History: He lives with his wife and their younger son in the suburbs. Their older son lives in a nearby town but comes home every weekend. The patient owns a car garage as the family business. He denies smoking tobacco or marijuana. Confirms taking alcohol occasionally when with his friends after work on weekends
Health Maintenance: Walks to the garage every day, which is about 1 km away from their house, as a form of exercise. Tries very hard to eat a balanced diet, as his wife cooks most of the days. Shows up for routine screening every year.
Immunization History:Up to date. Covid-19 vaccine received on 4th Feb 2021 fist shot and Moderna booster on 5th March 2021. Flu shot receive last on 12/12/2021.
Significant Family History:
Father: with hypertension, and diabetes
Mother: Died from a heart attack.
Younger son: asthmatic
Review of Systems:
General: No weakness, fatigue, nausea, or vomiting. The patient denies any recent changes in body weight.
HEENT:No visual defects. Denies use of corrective glasses. No excessive tearing or redness of the eye. Denies discharge or ear tenderness. No running nose or congestion. Denies sore throat or dental carries.
Neck:No swelling or lump spotted.
Breasts:Asymmetric in size with no lumps or nodules.
Respiratory:No shortness of breath, wheezing, cough, or chest pressure.
Cardiovascular/Peripheral Vascular:No chest pain or palpitations.
Gastrointestinal:No Tenderness, diarrhea, vomiting, abdominal pain or discomfort, bloating, jaundice, constipation, or changes in bowel movement.
Genitourinary:No changes in urine frequency or urgency.
Musculoskeletal:Complaints of pain and swelling of the left lower extremities. Confirms warmth and ecchymosis.Decreased ROM in the leftleg. Full range of movement with no pain on the right leg.
Psychiatric:Denies any history of depression, anxiety, or mood disorders.
Neurological:Denies headache, dizziness, nausea, vomiting, ataxia, paresthesia of syncope.
Skin: No rashes, itching, sores, or dryness.
Hematologic/Lymphatic: No history of anemia, bleeding problems, or prolonged healing of wounds. Denies any signs of enlarged lymph nodes or a history of splenectomy.
Endocrine:No heat or cold intolerance. Denies excessive sweating, polyuria, or polydipsia.
Allergic/Immunologic: Seasonal allergy.
OBJECTIVE DATA:
Physical Exam:
Vital signs:: T- 98.0 °F; Pulse- 66; Rr 16; BP 138/79; Height 5’6’’, Wt. 188 lb. 15
General: The patient appears sickly and walks with difficulties. She is well-groomed and able to respond to questions appropriately. She is very cooperative and pleasant. She, however, appears energetic, with distress only on the left leg.
HEENT:Eyes: Moist conjunctiva, anicteric sclera; no lid lag; PERRLAEars, Nose, Mouth & Throat: Clear oropharynx with moist mucous membranes. No signs of mucosal ulcerations. Full dentition with no signs of bleeding gums. Hard and soft palates were noted with no abnormalities.
Neck:Carotids no bruit, jugular vein distention, or enlarged thyroid gland. Chest/Lungs: Anterior chest wall, bilaterally non-tender to palpation. Bilaterally equal expansions were noted.Bilaterally clear to auscultation. Prolonged expiratory phase. No wheezing, rhonchi, or rales.
Heart/Peripheral Vascular: S1 and S2 noted. Systolic murmur, 2/6. Regular heart rate and rhythm. No gallop or rales were noted.
Abdomen:The patient had bowel sounds present, non-tender, non-distended, obese, soft, no CVA tenderness.
Genital/Rectal:No abnormalities were noted in the genital or rectal area.
Musculoskeletal: Left lower limb edema and erythematous in the arch and along the entire anterior aspect of the left leg up to the mid-shin. No open wounds were noted with drainage. Tenderness in the left lower leg was noted with increased warmth relative to the right leg.
Neurological: Grossly intact. Cranial nerves II through XII.
Skin:Warm and dry, with no rash or lesions.
Diagnostic results:
WBC: 10.1
HGB: 13.2
HCT: 41.2
MCV: 85
BUN: 17
Imaging: X-Ray reveals no deformities (Dains et al., 2019).
ASSESSMENT:
Primary Diagnosis
- Cellulitis of the leg: This disorder is normally diagnosed based on patient history and findings of physical examinations. The patient in the provided case study presented with all the indicating signs and symptoms to qualify for the diagnosis of cellulitis such as worsening tenderness, warmth, redness, swelling, and erythema for 3 days (Edwards et al., 2020). However, a skin sample must be taken to confirm the causative bacteria present.
Differential Diagnosis:
- Lymphedema: It is usually characterized by a disrupted or damaged lymphatic system causing drainage (McPhillips et al., 2021). It mostly affects the arms and legs with presenting symptoms such as pain and swelling just like for the case of the patient in the provided case study. Lymphoscintigraphy tests and Doppler ultrasound are however needed to confirm this diagnosis.
- Osteomyelitis: It is characterized by swelling and tenderness of the bonny tissue (Liu et al., 2020). It is usually caused by an infection. Needle aspiration, bone biopsy, and blood tests are however required to confirm this diagnosis.
- Acute dermatitis: This condition is usually characterized by swelling and redness of the skin with blisters (Rrapi et al., 2021). The patient in the provided case study did not present with blisters disqualifying this diagnosis.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.