Assignment: Comprehensive SOAP: Differential Diagnosis for Skin Conditions

Assignment: Comprehensive SOAP: Differential Diagnosis for Skin Conditions

Assignment: Comprehensive SOAP: Differential Diagnosis for Skin Conditions

Differential Diagnosis for Skin Conditions

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.

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• 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.
• 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.

The first assignment is formulating differential diagnoses for skin conditions. In this assignment you will choose a skin condition from the learning resources. Identify your skin condition by number in the chief complaint. You will document this assignment in SOAP format. You will make up the missing parts of the SOAP note such as meds, hx, ROS and Physical Exam. Please use the SOAP template provided in the learning resources. Please list three to five differential diagnoses for the skin graphic you chose. Out of these, determine which diagnosis is the most likely diagnosis and provide a rationale to explain why you chose that diagnosis. You should provide at least three different references.

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Comprehensive SOAP: Differential Diagnosis for Skin Conditions

 Patient Initials: F.W              Age: 27 years           Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “Stretch marks on the abdomen.” (Image 2)

History of Present Illness (HPI): F.W is an African American woman who presented for her fourth antenatal care visit. She reported that the stretch marks on her abdomen are increasing daily, affecting her body image. F.W is a para 0+0, gravida 1, and currently at 32 weeks GBD. She states that the stretch marks started appearing at 20 weeks gestation and have worsened despite moisturizing her skin with a cocoa butter lotion four times a day. The client expresses worry that she might not be able to wear a cutoff shirt or a bikini after her pregnancy. She is also worried that the stretch marks will result in sagged skin after delivery, significantly affecting her body image. The client reports using OTC moisturizing cream that claims to reduce the appearance of stretch marks, but they were ineffective.

Medications:

Iron and Folic Supplements for pregnancy.

Allergies:

No drug/ seasonal/food allergies.

 Past Medical History (PMH):

No history of chronic illnesses.

Past Surgical History (PSH):

Tonsillectomy at 7 years.

Sexual/Reproductive History:

Para 0+0; Gravida 1. History of hyperemesis gravidarum at 12-16 weeks.

Personal/Social History:

The client is engaged and currently lives with her fiancé. She has a history of alcohol use but stopped after getting pregnant. She denies tobacco or illicit drug use. Immunization History:

Flu shot- 06/2022

Tdap- 05/2015

Covid Vaccine – 08/2021 J&J

Significant Family History:

Her paternal grandfather has DM and Kidney failure at 78 years.

Her maternal grandfather died from lung cancer at 82 years.

Parents and siblings are alive and well.

Lifestyle:

The client has a law degree and works as a paralegal in a law firm. She is working towards passing her Bar exams to become an advocate. She lives in a middle-income neighborhood in Queens, NY, with low crime, access to hospitals, and good transportation options. She has medical insurance paid for by her employer. She reports eating 5-6 small healthy meals per day since she was 16 weeks pregnant. Besides, she sleeps 8-9 hours per day. Her hobbies include watching movies and swimming.  

Review of Systems:

General: Positive for weight gain. Negative for fever, excessive fatigue, chills, or malaise.

HEENT: Head: Negative for headache or head injury. Eye: Denies blurred/double vision, excessive tearing, or eye pain. Ear: Negative for ear pain, discharge, or hearing loss. Nose: Denies sneezing, nasal congestion, or epistaxis. Throat: Denies dental pain, sore tongue, sore throat, or difficulty swallowing.

Neck: Negative for stiffness or pain.

Breasts: Positive for tenderness. Negative for history of nipple discharge, lumps, or masses.

Respiratory: Negative for cough, sputum, breathlessness, or chest pain.

CV: Negative for edema, exertional dyspnea, palpitations, or chest discomfort.

GI: Negative for nausea, vomiting, epigastric pain, abdominal cramping, diarrhea, or constipation.

GU: Positive for increased vaginal secretion and urinary frequency. Negative for malodorous PV discharge, vulvar irritation, dysuria, or bloody urine.

MS: Negative for joint pain, stiffness, or muscle/back pain.

Psych: Negative for depression, anxiety, sleeping disturbance, or suicidal ideations.

Neuro: Negative for muscle weakness, dizziness, headache, black spells, fainting, or tingling sensations.

Integument/Heme/Lymph: Positive for stretch marks and abdominal hyperpigmentation. Negative for itching, rashes, or lesions.

Endocrine: Positive for increased urine production. Negative for heat or cold intolerance, acute thirst, or excessive hunger.

Allergic/Immunologic: Negative for allergic infections.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 122/78, HR-86; Temp- 98.4; RR-20;

Wt: 158 lbs; Ht: 5’5.

General: AA female client in her 20s. The patient is alert, calm, and in no distress. She is well-groomed and appropriately dressed. She maintains eye contact and has a normal gait and posture.

HEENT: The head is normocephalic; PERRLA; TMs are intact and shiny; Pink and wet mucosal membranes; Tonsillar glands are non-erythematous.

Neck: Full ROM; Trachea is well-aligned. Thyroid gland normal on palpation.

Chest/Lungs: Smooth respirations; Chest clear on auscultation; S1 and S2 present. No systolic murmurs or S gallop. 

ABD: Round gravid abdomen. Slightly raised dark linear marks, irregularly shaped and perpendicular to the direction of skin tension. Linea nigra present. FHR- 144 b/min; Normoactive bowel sounds; Gravid mass on palpation.

Genital/Rectal: Normal female genitalia. No rectal fissures or ulcers are present.  

Musculoskeletal: Full ROM of all joints. 

Neuro: Muscle strength- 5/5. CN II – XII intact; DTRs- 2

Skin: Slightly raised dark linear marks on the abdomen. The marks are irregularly shaped and perpendicular to the direction of skin tension. The marks are depressed on palpation.

Lymph Nodes: Non-palpable.

Diagnostics/Lab Tests and Results:  No tests were ordered.

Assessment:

Differential Diagnosis (DDx):

Striae gravidarum: Striae (stretch marks) are fine lines on the body that are caused by tearing the tissue under the skin due to rapid growth or over-stretching. Striae gravidarum refers to stretch marks following pregnancy (Yu et al., 2022). It presents as atrophic linear scars. They are flat, pink-to-red bands that become raised, longer, wider, and violet-red (Yu et al., 2022). Striae gravidarum is the primary diagnosis based on the presence of slightly raised dark linear marks, irregularly shaped and perpendicular to the direction of skin tension.

Linear Focal Elastosis: Elastosis is an increased or abnormal deposition of elastin fibers within the dermis. Linear focal elastosis is a rare form of dermal elastosis similar to stretch marks. It is characterized by yellow, palpable lines that extend horizontally over the lower back (Florell et al., 2018). Linear focal elastosis is a differential diagnosis based on the palpable lines on the patient’s skin. However, the marks are on the abdomen and are depressed on palpation, making this an unlikely primary diagnosis.

Anetoderma:  Anetoderma is a rare skin condition in which the elastic tissue in the dermis is lost, causing depression in the skin. The classic clinical presentation of anetoderma is multiple rounds, well-defined lesions of 1–2 cm with wrinkly skin overlying a palpable depression (Genta et al., 2020). The lesions can be raised, flat, or depressed, skin-colored, or bluish-white. They are mostly found on the back, chest, neck, and arms. Anetoderma is an unlikely primary diagnosis since the patient has raised dark linear marks rather than lesions.

PLAN: [This section is not required for the assignments in this course but will be required for future courses.]

References

Florell, A. J., Wada, D. A., & Hawkes, J. E. (2018). Linear focal elastosis associated with exercise. JAAD case reports, 3(1), 39–41. https://doi.org/10.1016/j.jdcr.2016.10.012

 Genta, M. P., Abreu, 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

Yu, Y., Wu, H., Yin, H., & Lu, Q. (2022). Striae gravidarum and different modalities of therapy: a review and update. Journal of Dermatological Treatment, 33(3), 1243–1251. https://doi.org/10.1080/09546634.2020.1825614