SOAP NOTE Name: F.Z Date: 14th Sept, 2020 Time: 1600hrs ✓ Solved
Subjective
Chief Complaint (CC): Itchy skin lesions.
History of Present Illness (HPI): A male patient presents with itchy skin lesions that have been present for a few months. Initially noticed on the knees, the lesions have now extended to his elbows and scalp. He reports the lesions are slightly itchy, worsening over the last three weeks to a severity of 7/10, causing significant stress due to pain. He has attempted to change his bathing soap and has been using ibuprofen 400 mg three times a day for pain relief.
Medications: OTC Ibuprofen 400 mg PO every 6 hours and Ortho Tri-cyclin 1 tablet PO daily.
Past Medical History (PMH): No known drug allergies (NKDA); no history of medication intolerance; no chronic illnesses or major traumas; no history of hospitalization for hypertension, diabetes, asthma, peptic ulcers, lung disease, heart disease, tuberculosis, kidney problems, or thyroid issues.
Family History: Mother alive with diabetes; father deceased without known cause; maternal grandfather deceased with psoriasis.
Social History: The patient is a 68-year-old male undergraduate and retired teacher who enjoys farming. He reports no substance or alcohol use and lives with his wife and three grandchildren. He is stable and can perform his activities of daily living (ADLs) independently.
Review of Systems (ROS):
General: Denies chills, fever, weight changes, night sweats, and fatigue.
Cardiovascular: Denies palpitations, chest pain, paroxysmal nocturnal dyspnea (PND), orthopnea, and edema.
Skin: Reports delayed healing, bruises, discoloration, and presence of moles and lesions.
Respiratory: Denies cough, wheezing, dyspnea, or history of pneumonia or tuberculosis.
Eyes: Denies need for corrective lenses, blurring, or changes in vision.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, ulcers, or other gastrointestinal concerns.
Ears: Denies ear discharge, pain, hearing loss, or tinnitus.
Genitourinary/Gynecological: Denies changes in urinary frequency or urgency; no urinary issues reported.
Nose/Mouth/Throat: Denies sinus issues, dysphagia, nasal bleeding, dental issues, hoarseness, or throat pain.
Musculoskeletal: Confirms pain and swelling in the knee and elbow; denies fractures or stiffness.
Neurological: Denies syncope, seizures, transient paralysis, or paresthesia; notes weakness in right knee and elbow.
Heme/Lymph/Endo: Negative for HIV; reports bruising; denies previous blood transfusions or night sweats.
Psychiatric: Denies depression, suicidal thoughts, sleep difficulties, or anxiety.
Objective
Weight: 63 kg; BMI: 21.9; Temperature: 97°F; Blood Pressure: 120/68; Height: 170 cm; Pulse: 70; Respiration: 16.
General Appearance: Patient appears healthy and oriented. In no acute distress and responds appropriately.
Skin: Rashes and lesions noted; skin integrity is compromised.
HEENT Exam: Normocephalic head; no lesions; evenly distributed hair; PERRLA; intact extraocular movements; no conjunctival injection.
Ears: Patency and normal appearance noted. No abnormal findings in the nose or throat.
Cardiovascular: Regular rate and rhythm, S1 and S2 present with no abnormal sounds.
Respiratory: Clear lung sounds bilaterally, symmetric chest wall movement observed.
Gastrointestinal: Abdomen soft and non-tender, active bowel sounds in all quadrants.
Musculoskeletal: Full range of motion in all extremities.
Neurological: Clear speech and normal tone, stable gait.
Lab Tests: Complete blood count indicated to assist in determining the cause of itching; chest X-rays indicate no significant findings; skin biopsy may be needed for further evaluation; skin culture to identify any infectious organisms.
Diagnosis: Differential diagnoses include squamous cell carcinoma, benign skin lesions, and actinic keratosis, with a primary diagnosis of basal cell carcinoma.
Plan/Therapeutics:
- Further testing: Skin culture and histological analysis for confirmation of nodular basal cell carcinoma.
- Medications: Prescription for topical anti-tumor medications, chemotherapy, and potential surgery options.
- Education: Patient educated on avoiding exacerbating factors like sun exposure and tanning beds.
- Non-medication treatments: Cryotherapy, curettage, laser surgery, and radiation therapy may be considered.
Evaluation: The patient is alert and well-oriented but has concerns regarding his condition. Education on the diagnosis and treatment options needs to be provided to him for better understanding and compliance.
References
- Ely, J. W., Rosenfield, S., & Seabury, S. M. (2014). Diagnosis and management of tinea infections. Am Fam Physician, 90(10).
- Habif, T. P. (2016). Clinical Dermatology: A Color Guide to Diagnosis and Therapy. (6th ed.). Mosby.
- Kim, J. Y., Kozlow, J. H., Metta, B., Moyer, J., Olenecki, T., & Rodgers, P. (2018). Guidelines of care for the management of cutaneous squamous cell carcinomas. Journal of American Academy Dermatology, 78(3).