Week 4 Intergumentary

NURS 6512N

Advanced Health Assessment

Walden University

Week 4Assignment

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SOAP NOTE

Differential Diagnosis for Skin Condition

Skin Condition Picture #5

Patient Initials: AP Age: 69 Gender: M

SUBJECTIVE DATA:

Chief Complaint (CC): Complains of rash that have some blisters and scab on the chest and

back.

History of Present Illness (HPI): Mike Jones is a 69-years old Caucasian male who presents today with a new onset of clusters of rash and blisters on his anterior, right flank and posterior chest. He reports that 4 days prior to the rash appearing he had itching, tingling, burning and pain in the same area of the rash. He reports the severity of pain 7/10 and 10/10 with palpation.

Medications:

1. Tamsulosin (Flomax) 0.4 mg for BPH

2. Over the counter Aspirin 81 mg daily

3. Over the counter Benadryl 25mg 1 tab every 6 hours for itching.

4. Over-the-counter topical hydrocortisone cream for itching as needed.

5. Over-the-counter Tylenol extra strength two tablets every 6 hours for pain.

Allergies: No Know Drug Allergies

Past Medical History (PMH):

1. Benign prostatic hyperplasia – age 50

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2. History of gallstone- age 45

3. Chickenpox – age 6

4. Chlamydia-age 25

Past Surgical History (PSH):

1. Cholecystectomy 2010-age 59

2. Transurethral resection of the prostate 2012 – age 61

Sexual/Reproductive History:

Heterosexual

Personal/Social History: Past tobacco product use, quit more than 30 years ago, denies ETOH,

or illicit drug use. He enjoys fishing and camping with his friends and visiting with his children

and grandchildren as often as he can. He drinks an occasional glass of wine or beer at social

gathering.

Immunization History: His immunizations are up to date. Patient last Influenza vaccine was

two weeks ago. Received the pneumococcal vaccine at age 65. Believe all childhood vaccination

was received. Last Tdap received when he was in college.

Significant Family History:

Natural death- Mother-deceased at age 90.

Gout, hemorrhagic stroke, hypertension, ETOH -Dad age 92.

Cervical Cancer- Maternal grandmother died at age 86.

Congestive heart failure, Asthma, COPD – Maternal grandfather- die at age 75.

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Drown-Paternal grandmother – deceased at age 35 in a boating accident.

Stroke, Hypertension - Paternal grandfather, deceased, at age 70.

Lifestyle

Patient is married to his wife of 30 years with two adult children and 3 grandchildren. He owns a

business that sell different insurance product. He in the process of handing the business over to

his two children who current work with him to retire next year. The patient is petty active both

him and his wife walk at least for an hour three to four times a week.

Review of Systems:

General: Patient denies fever, fatigue, or poor appetite. Endorse severe pain at the site of the

rash.

HEENT: Denies any head injury or headaches, blurred vision or floaters. Does yearly eye exam,

appointment coming up in three months. History of astigmatism but had Lasik surgery10 years

ago. Negative for hearing loss, tinnitus, or ear pain. Have issue with excessive wax for which he

sees an ENT specialist for cleaning one a year. Last cleaning was two months ago. Denies any

issue or history of nose- bleed, post-nasal drip, congestion or change in smell or recent cold.

Patient denies any dry mouth, throat soreness, cough or history of strep throat. Patient had dental

implant done two years ago.

Neck: No complaints of pain or discomfort, no swollen lymph nodes. No jugular veins

distention.

Breast: Denies tenderness/discomfort. No drainage or gynecomastia.

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Respiratory: No shortness of breath, cough, or congestions. Denies chest pain or discomfort.

No environmental exposure, no exposure to second- hand smoking. No history of pneumonia or

tuberculosis.

CV: No complaints of chest pain, palpitation or dyspnea on exertion. No edema, history of

syncope, rheumatic, claudication or thrombophlebitis. Negative for hypertension or abnormal

electrocardiogram

GI: Denies any nausea, vomiting, diarrhea , constipation, change in appetite, bowel pattern

every three days. No history of hemorrhoid, rectal bleeding, food intolerance or indigestion.

Patient has a history of gallbladder disease.

GU: no dysuria, penile pain or discharge, hematuria, no testicular pain, history of urinary tract

disease or hernias. Patient has history dribbling after urination, nocturia, frequent urination, sense of

incomplete bladder emptying, urinary urgency to urinate and a weak urinary stream. Abnormal

ejaculatory patterns. No history of STDs.

MS: He has no complaints of arthritis or muscle pain. Slipped and fell in the snow last year, no

injury or fracture. Positive Trendelenburg gait, range of motion of both upper and lower

extremities.

PSYCH: Denies any depression, suicidal ideation or homicidal ideation, anxiety, hallucinations

nightmares, insomnia. Has a phobia to clowns

NEURO: negative for headaches, weakness, numbness, tingling or tremors. No visual changes,

seizures, blackouts, memory changes, vertigo or dizziness.

INTEGUMENT/HEME/LYMPH: Scatter and cluster rash on anterior and posterior chest. No

other skin abnormalities present.

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ENDOCRINE: No abnormalities in this area. No hormone therapy at this time.

ALLERGIC/IMMUNOLOGIC: No history of environmental, food or medication allergies

and no immune deficiencies.

OBJECTIVE DATA

PHYSICAL EXAM: B/P 156/90, left arm, sitting, regular adult cuff; P 82 and regular; T 98.9

orally; RR 18 and non-labored; Wt: 147 lbs.; Ht: 5’6.

General: Alert, interactive, and well nourished. Appears uncomfortable and guarding the right

upper body.

HEENT: No visual deformities to his head. No history of injury or complaints of headache.

Patient had Lasik surgery of bilateral eyes 10 years ago, PERRLA, no conjunctivitis. No

difficulty hearing, ear canal clean, tympanic membranes are pink with land mask’s visible. No

post -nasal drip or polyps seen. No redness or complaint of soreness or irritation of throat. Oral

mucosa is pink and moist. Tonsils are of normal shape and size.

Chest/Lungs: Chest is symmetrical. Lung sounds equal and clear to auscultation, in all lung

field, no crackle or wheezing. Respiration are even and non-labored.

Heart/Peripheral Vascular: Blood pressure slightly elevated systolic in the 150's. Heart rate

and rhythm normal with S1 and S2 sound without the presence of gallops or murmurs.

ABD: Abdomen soft, non-tender, nondistended with the present of active bowel sound in all

quadrant

Genital/Rectal: External genital WNL, circumcised without the presence of lesions or wounds.

No signs of hemorrhoid.

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Musculoskeletal: AROM to upper and lower extremities. No history of trauma or fractures.

Unable to completely abduct right hip.

Neuro: Appropriately response to quarry for age. No abnormal sensory or weakness noted.

Skin/Lymph Nodes: Open and fluid fill blister seen on the chest, right flank and back.

ASSESSMENT:

LAB TEST AND RESULTS:

SPO2, 95% on room air.

CBC: WBC 7,000; RBC: 14 GM/DL

PCR- Polymerase chain reaction (PCR)- 210.9

DIFFERENTIAL DX:

• Eczema

• Contact Dermatitis

• Shingles

DIAGNOSIS/CLIENT PROBLEM

Diagnosing Shingles in the early stages can be difficult because the typical rash often only appears after

the pain starts. Depending on what part of your body is affected, other causes might be suspected at

first, like an inflammation of the appendix (appendicitis) or an inflammation of the gallbladder

(cholecystitis), a slipped disk or even a heart attack.

Many people who have shingles first think that it might be a non-contagious skin condition like eczema. This may delay the diagnosis because they might think that they don’t need to see a doctor about it.

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Doctors diagnose shingles based on its typical one-sided rash and the accompanying pain or abnormal sensations. If they aren’t sure whether it’s shingles, the fluid inside the blisters can be tested to see whether it contains the virus. Doctors can also check if the blood contains more than the usual numbers of antibodies needed to fight the varicella-zoster virus

InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and

Efficiency in Health Care (IQWiG); 2006-. Shingles: Overview. 2014 Nov 19

[Updated 2019 Nov 21]. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK279624

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References

Ball, Jane et. al. (2015). Seidel’s Guide to physical examination (8th ed.) St. Louis, MO: Elsevier

Mosby.

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