skin condition
whinny
mywork.docxComprehensive SOAP Template
Patient Initials: __AM_ Age: _____38_ Gender: ___F_
SUBJECTIVE DATA:
Slide No 3
Chief Complaint (CC):
Patient present with multiple lesions on he left thigh that been present for several weeks, approximately 3 months.
History of Present Illness (HPI):
AM is a 38 years old Caucasian female presented to the clinic with multiple lesions on her left shoulder. Patient reported that lesion has been presents for about 2-3 months. Per patient, “I noticed like a nodule about 3 months ago now it’s about 4 nodules”. The lesion is palpable elevation which appears to be solid, firm and painless on examination. The nodules dimples in the middle when touched. Patient denies pains but says it could be painful when knocked. The nodules are about 5mm above the skin. Patient could not ascertain if nodules has increased in size. Pt is worried that it could be tumors or cancer. Pt has a family history of cancers or tumors.
Medications:
1. Nifedipine XL30mg by mouth daily for Hypertension
2. Lipitor 10 mg by mouth once daily at bedtime for high cholesterol
Allergies:
Medication allergies- Penicillin react with Hives
Denies food allergies or latex allergue
Past Medical History (PMH):
1. Primary Hypertension: diagnosed at age 28
2. Hyperlipidemia: diagnosed at age 30- control with medication, diet and exercise
Past Surgical History (PSH):
1. Cesarean sections- 2007 for her second pregnancy
2. Cholecystectomy - 2015
Sexual/Reproductive History:
Patient is sexually active. She is not currently any birth control, says husband uses condom. Patient has regular (28 days) menstrual cycle. She is married with 2 children.
Personal/Social History:
Patient denies alcohol and illicit drug use. Never a smoker. She is active around the house and tried to eat healthy. Patient is a case manager and lives in a rented apartment. Patient is married with 2 children (a boy 18 and a girl 13). She takes a brisk walk of about 30 minutes every day after work.
Immunization History:
Patient believes to be up to date on immunization. Patient received flu vaccine September 2019.
Significant Family History:
Patient’s father is deceased, died of heart attack in 2011 at age 62. Mother (68) is still alive with medical history of obesity, hyperlipidemia, hypertension and type 11 diabetes. Patient has a brother with medical history of Hypertension. Paternal grand father died of skin cancer
She is Christian and believes in God. She attends a catholic church every Sunday Mass as
well as midweek mass.
Review of Systems:
General: Ms AM is alert and oriented. Calm and cooperative. Ms. AM endorsed recent weight lost and general body weakness sometimes.
HEENT:
Pt denies headache, dizziness, Pt denies any visual impairment, but wears glasses for near sightedness, no blurry vision, had her last eye exam a month ago (02/19/2020), no floaters. No difficulty in earing, no ringing in the ear, denies hearing loss. No ear infection, no ear pain or discharge. No nasal pain or drainage. No nose bleeds. Denies tooth pain/ache, No dental carries, No sore throat, denies painful/ difficulty in swallowing, denies mouth sores. No loose tooth, last dental visit (01/20/2020),
Neck:
Fullness in range of motion. No thyromegaly. No carotid bruits. No masses palpated. No tracheal deviation noted
Breasts:
Breast is symmetric. Negative to dimples
Respiratory:
. No dyspnea, tachypnea or hypopnea observed. Denies night sweat, wheezing, prolong cough. No hematemesis. Pt denies respiratory complaint.
CV:
No abnormal heart sound heard. Palpable peripheral pulses. Symmetric pulse volume. Good capillary refill. No peripheral tenderness or edema. No negative to chest pain. Pt is positive to hypertension. Electrocardiogram is normal sinus rhythm.
GI:
Audible bowel sounds. Denies pain or tenderness. No ascites observed. No abdominal Ulcer. Denies nausea or vomiting. No dysphagia, No hematemesis. No constipation. No diarrhea. Endorse loss of appetite lately. No heartburn or indigestion.
GU:
Negative to dysuria, no blood in urine. No urgency or increase in frequency of urination. Positive to polyuria, negative to vaginal discharge. Negative to dyspareunia. Negative for hemorrhoid.
MS:
Negative to joint pain. Swollen left axillary lymph node. Positive to fatigue and body weakness. Steady gait. Overweight.
Psych:
Positive self-esteem. Negative for suicidal ideation or homicidal ideation. Negative for hallucinations and grandiosity. Positive for mild anxiety as a result of nodules on the left arm.
Neuro:
No headache, dizziness, no numbness or tingling sensation. No loss of balance. Negative for tremors
Integument/Heme/Lymph:
She has a solid, firm and painless lesion on the left arm.
Endocrine:
Negative for polydipsia, polyphagia. Positive for polyuria.
.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Blood pressure 145/86 on the left arm, lying, pulse 84 and regular; Temperature 97.8 orally; RR 18 non-labored; oxygen saturation 99% at room air, weight: 264 pounds; height: 5’ 5”; and blood glucose 140 at 2 hours post pandial
General: Pt i alert and oriented to time, place, and person. Pt is calm and cooperative
HEENT: PERRLA; head is normocephalic, pupil is reactive to light. accommodation, speech
Neck: Carotids no bruit,
Chest/Lungs: Bilateral lung sound heard. Quiet rhythmic and effortless respiration. Full Symmetric respiratory effort. Chest is symmetric respiration is even,
ABD: soft non tender
Genital/Rectal: bowel sound heard on all quadrant, no ascites.
Musculoskeletal: strong
Neuro: intact
Skin/Lymph Nodes: skin is warm to touch. Axillary lymph nodes palpated.
ASSESSMENT:
Lab Tests and Results:
Diagnostics:
Labs: CBC with differential, CMP
Radiology: Chest x-ray
EKG:
Differential Diagnosis (DDx):
Cherry Angioma
Glomeruloid hemagiona
Angikeratoma corporis diffusum
Cherry angioma- Cherry angioma (CA) is the most common type of acquired benign vascular proliferation which usually presents as non-blanching red papules on the acral and truncal areas (Darjani, et al., 2018). CA has been seen in 2% of children, 50%ofadults, and 50%–75% of people aged older than 75 years old (Darjani, et al.,)
2.) Glomeruloid hemangioma- A small, firm, red dome-shaped papules subcutaneous bluish compressible tumors, wine-red pedunculated papules. They range in size, measuring few millimeters to few centimeters in diameter, and are located mainly on the trunk and proximal limbs and is characterized by a solitary or multiple blue-red papule (Gupta, Kandhari, Ramesh, and Singh, 2013).
3.) Angiokeratoma corporis diffusum- Angiokeratomas are hyperkeratotic papules that are characterized histologically by superficial ectatic vessels with epidermal proliferation. Red to purple, hyperkeratotic and coalescing papules, occurs most typically on the lower region of the trunk, buttocks, and thighs and is usually associated with Lyosomal storage diseases (Jayavardhana, Balasubramanian, and Vijayalakshmi, 2015).
Diagnoses/Client Problems of Image #2:
1.) Cherry angioma
2.) Hypertension
3.) Hyperlipidemia
.
References
Darjani, A., Rafiei, R., Shafaei, S., Rafiei, E., Eftekhari, H., Alizade, N., … Najirad, S. (2018). Evaluation of Lipid Profile in Patients with Cherry Angioma: A Case-Control Study in Guilan, Iran. Dermatology Research & Practice, 1–5. https://doi-org.ezp.waldenulibrary.org/10.1155/2018/4639248
Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid hemangioma in normal individuals. Indian Journal Of Dermatology, 58(2), 160. doi:10.4103/0019-5154.108088
Jayavardhana, A., Balasubramanian, P., & Vijayalakshmi, A. M. (2015). Angiokeratoma corporis diffusum. Indian Pediatrics, 52(2), 175. Retrieved from Walden Library database
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