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.

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Comprehensive SOAP Template

 

 

 

       Patient Initials: DM                                 Age: 27                                           Gender: M

 

 

Subjective data: “I have noticed a dry rash, that’s cracking and itching and is getting worst.”

 Chief Complaint (CC): Skin condition #5.  Skin aberration observed roughly 2 weeks ago and getting increasingly worse in dryness with some bleeding to the site.  The area affected is mainly the elbow and forearm.

 History of Present Illness (HPI):  DM is a 27-year-old male presenting to the clinic with patchy, flaky, and scaly skin on the elbow and forearm.  Patient reports an on set of about 2-3 weeks and getting increasingly worst.   Patient cannot recall making changes in his toiletries that could result in the manifestation of this problem. The patient who is employed as a project manager in an oil company is going through a stressful period as he has been told to lay off some of his staff because of economic reasons. He reported having some sleepless night deciding who to get rid of. He reports no pain but occasional itching. His fiancée has bought some Gold bond cream which has not been very helpful in relieving the itching.

Medications: None

Allergies: Seasonal allergies

Past Medical History (PMH): Appendicitis

Past Surgical History (PSH):  Appendectomy

Sexual/Reproductive History: N/A

Personal/Social History:  Drinks socially, denies tobacco use, no risky sexual behavior has one partner, patient is engaged

Immunization History:  Immunizations are up to date.  Last Tdap Fall 2017, Flu September 2018, pneumonia 2011

Significant Family History:  Father:   DM type 2.

 Mother:  HTN.  Reports no siblings or children 

Lifestyle:  Patient is a African American male who is a project manager for an oil company going through the process of laying off some of his staff. He reports being relatively comfortable with minimal debt,