Lab Assignment: Differential Diagnosis for Skin Conditions
By utilizing effective techniques for conducting patient interviews and physical
examinations, clinicians compile subjective and objective data that help determine a primary
diagnosis out of a myriad of differential diagnoses. In this case study assignment, I will outline
physical characteristics of the skin condition presented in slide # 3, present subjective and
objective data for potential diagnoses, and provide evidence to support the primary diagnosis.
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: __MT__ Age: ____35___ Gender: __M____
SUBJECTIVE DATA:
Chief Complaint (CC): rash and discomfort to left chin (Slide # 3)
Physical Characteristics: Localized papulopustular skin eruptions on an
erythematous base, with irregular margins, and are centralized around hair
perforations (Ball et al., 2019; Dains et al., 2019). The presence of secondary
crusting of exudate indicates evolution of the primary lesion (Dains et al., 2019).
History of Present Illness (HPI): Mike T is a 35-year-old white male that
presents to the clinic for a skin rash and pain to left chin x 1 week. He stated that
after shaving 7 days ago, he noticed an ingrown hair and small, reddened
bumps. The area worsened after Mr. T attempted to extract the ingrown hair 3
days ago. He reports the development and rupture of multiple “pimples”,
expanding redness, wound crusting, and localized tenderness to the left side of
his chin. He rates the discomfort as 6/10 and characterizes his pain as throbbing.
He denies radicular pain. He reports pain relief with the application of cool packs
to the affected area. Aggravating factors include touch, talking, and “picking at it”.
Associated symptoms include spreading of redness, focal swelling, itching, and
the presence of pus-like drainage upon “pimple” manipulation. He washes the
area daily and keeps the wound covered with a bandage. However, he reports “I
just keep picking at it.” He denies using topical ointments on the area.
Medications:
Metformin 500mg po bid for T2DM, last dose “two or three days ago”
Losartan po daily for HTN, last dose this A.M.
Multivitamin 1 tab po daily, last dose yesterday
OTC Advil 200-400mg po tid prn for pain, last dose 0800 today
Order this paper