Week 4 Assignment Sample Paper NURS 6512 – Lab Assignment: Differential Diagnosis for Skin Conditions SOAP Note

 

Student’s Name:

Institutional Affiliation:

 

 

 

 

Comprehensive SOAP NOTE

Patient Initials: ___N/A____              Age: ___N/A____                              Gender: ___N/A____

SUBJECTIVE DATA:

Chief Complaint (CC): #3

History of Present Illness (HPI):   A Caucasian male whose age is unknown presents with non-scaly annual papules distributed along his nape. The papules have undiluted borders and appear reddish in color.

Medications:  No medical history provided.

Allergies: No known allergies.

Past Medical History (PMH): Past medical history not provided.

Past Surgical History (PSH): No surgical history provided.

Sexual/Reproductive History: Not provided. Ask about his sexuality, the number of sexual partners, pregnancy, and whether the patient has a history of sexually transmitted infections.

Personal/Social History: Not provided. Enquire on his hobbies, place of work, traveling history, and whether he smokes or use any recreational drugs.

Immunization History: Not provided. Collect the patient immunization details.

 

Significant Family History: Not provided. Inquire if there are family members with any skin complications. Inquire about other family’s medical conditions that might contribute to skin infections.

Review of Systems:

General:  Not reported. Inquire for symptoms of fatigue, fever, sweating, or any significant weight changes.

HEENT: Not reported. Inquire about any vision or hearing changes, any chewing or swallowing difficulty, and any nasal complications.

Neck: Red lesions distributed on the back of the neck.

Breasts:  No reported complications. Ask if the patient has a history of lesions, masses, or rashes.

Respiratory:  No reported complications.

CV: No reported complications.

GI: No reported complications.

GU:  No reported complications. Ask if the patient has had any lesions or rashes on his genital areas.

MS: No reported complications.

Psych: No reported complications.

 

Neuro: No reported complications.

Integument/Heme/Lymph:  Red lesions at the back of the neck.  Ask if the lesions are present in other parts of the body.

Endocrine: No endocrine symptoms reported.

Allergic/Immunologic: No known allergies.

OBJECTIVE DATA

Physical Exam:

Check for the patient’s vital signs. Vital signs include blood pressure, temperature, heart rate, and body mass index.

General: Check for the patient’s appearance and signs of fatigue and discomfort.

HEENT: Investigate the eyes, ears, and nose for any abnormalities.

Neck: Non-scaly annual papules at the back of the neck. Palpate the lesions to determine the texture and warmness.

Chest/Lungs: Check the chest for the presence or rashes or lesions.

Heart/Peripheral Vascular: N/A

ABD:  Check the abdomen for the presence of rashes or lesions

Genital/Rectal:  Investigate the genitalia for the presence of rashes.

 

Musculoskeletal: N/A

Neuro: N/A

Skin/Lymph Nodes:  Non-scaly annual lesions at the back of the neck. Check whether there are further lesions on other skin regions.

ASSESSMENT:

Diagnostics:

Lab:

Various laboratory procedures can be used to guide the diagnosis. The following are some of the recommended procedures.

Dermoscopy. The procedure uses a skin surface microscope known as a dermatoscope to magnify the lesion (Colyar, 2015). The process aims at providing a more detailed investigation of the lesion to make a diagnosis and determine the skin lesions that require a biopsy (Colyar, 2015).

 

Diascopy. Th

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