Skin SOAP Note
Type: SOAP Note
Subject: Comprehensive SOAP Exemplar
Subject area: Nursing
Education Level: Undergraduate
Length: 6 pages
Referencing style: APA
Preferred English: US English
Spacing Option: Double
Title: Skin Conditions Assignment
Assignments-Skin Condition
Health Assessment
Walden University
March 22nd, 2023.
Patient particulars
Name: J.W.
Age: 56years
Gender: Female
Race: African
Subjective Data
Chief complaint: (5) skin rash and body itchiness for two weeks
History of presenting illness: J.W. is a 56years old African female with complaints of skin rash on the left back side associated with skin itchiness. These symptoms have been of gradual onset, increasing in severity over time. It is associated with iritis, headache, pleurisy, malaise, myalgia, fever, photophobia, and pain surrounding the rash. The pain is constant and severe without radiating to other organs.
Current medication: metformin 1g P.O. twice daily and HAART.
Allergies: the patent denies food, environmental, latex, and drug allergy.
Past medical history: the patient has had type two diabetes mellitus and HIV&AIDS since childhood. She has been on follow-up at the comprehensive care clinic. Her immunization schedule is up to date. Her last influenza and meningococcal vaccine were six months ago.
Past surgical history: the patient denies major or minor surgical procedure
Social history: J.W. is married and lives with her husband. She has five children; three boys and two girls. They are all grown and live far apart from each other. She works at the telephone center as the operations manager. She has studied up to university with a bachelor of telecommunication. She enjoys playing golf, reading novels, smoking cigarettes, and drinking whisky over the weekends. She does not engage in physical exercise.
Family history: the patient is the first child in a family of three. Her parents passed on ten years ago due to complications of HIV &aids. Her younger siblings are alive and healthy with no record of illness. Her children are healthy with no history of the disease.
Review of systems
General: the patient has a fever and fatigue. She denies chills, rigors, weight loss, and night sweats.
HEENT: the patient denies headache and photophobia. She denies dizziness, blurring of vision, ear pain, runny nose, and throat pain.
Respiratory system: the patient denies coughing, chest pain, wheezing, shortness of breath, and sputum.
Cardiovascular system: the patient denies chest pain, shortness of breath, palpitations, orthopnea, syncope, dyspnea, paroxysmal nocturnal dyspnea, claudication, and lower limb swelling.
Gastrointestinal system: the patient denies abdominal pain, diarrhea, vomiting, constipation, nausea, reflux, and heartburn.
Objective Data
General: the patient is calm and oriented. She has cervical and axillary lymphadenopathy. She has no pallor, jaundice, cyanosis, and dehydration.
Vitals: blood pressure at 112/86mmhg, pulse rate at 89beats per minute, temperature at 102f, and oxygen saturation at 98% room air.
Local examination: the patient has a rash on the left back side from the spinal line extending to the left shoulder. The rash is vesicular with segments of clouded, raptured, crusted, and involutes. The blisters are in a patchy erythematous base accompanied by induration with one dermatome area. The blisters are grouped in herpetiform cysts developing on the floor. The dermatomal area is erythematous and tender on palpation.
Diagnostic investigations: blood cultures to identify the pathogen-causing organisms. Complete blood count with differentials to rule out other infections. Direct fluorescent antibody testing of the vesicular fluid. Polymerase chain reaction testing of the varicella fluid or blood to identify herpes zoster.
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Assessment
Differential diagnosis
- Herpes Zoster
- Chickenpox
- Contact dermatitis
- Cellulitis
- Erysipelas
Herpes Zoster
It is caused by the Varicella zoster virus which commonly is presented with unilateral dermatomal vesicular eruptions. The rash may develop from just a tingling effect to a severe rash by 1-5 days. The rash always involves a single dermatome and do not cross the midline. The most risk factor for reactivation is immunosenescence or advancing in age, hence scientifically, the incidence of herpes zoster dramatically increases with age (Nash et al., 2023). Other important risk factors include HIV infections, use of drugs and hematologic malignancy. Patients who have herpes present pain as a common factor which may last for over 30 days following the onset of the rash.
The patient has a rash on the left back side from the spinal line extending to the left shoulder which is consistent with Herpes presentation of single dermatome that do not cross the midline. The rash is vesicular with segments of clouded, raptured, crusted, and involutes. The blisters are in a patchy erythematous base accompanied by induration with one dermatome area. The blisters are grouped in herpetiform cysts developing on the floor. The dermatomal area is erythematous and tender on palpation (Nash et al., 2023). Additionally, the patient has had type two diabetes mellitus and HIV&AIDS since childhood and smokes cigarette which is consistent with the risk factors of herpes zosters. Therefore, herpes zosters are the primary diagnosis because of the resemblance in its presentation and its mechanism of action.
Chickenpox
This is a contagious viral infection which causes an itchy feeling which cause blister-like rash on the skin for people of all ages. It however has vaccinations which may prevent its infection rate. It normally lasts for about 4-7 days. The rash caused by chickenpox may show up on the chest, back and face and then spreads over the entire body including inside the mouth, the genital area and eyelids. Other common symptoms include fever, tiredness, loss of appetite and headache. Risk factors of chickenpox include; people with HIV infection or cancer, people who have had transplants and those in immunosuppressive medications or long-term steroids (Yokota et al., 2020). Symptoms include itchiness and development of a blister like rash on the skin. While our patient has some similar symptoms to chickenpox, it is not our primary diagnosis because our patients’ rash involves a single dermatome and do not cross the midline which is inconsistent with symptoms of chickenpox which may show up on the chest, back and face and then spreads over the entire body including inside the mouth, the genital area and eyelids. Additionally, while chickenpox is contagious, our patient’s younger siblings are alive and healthy with no record of illness. In fact, her children are healthy with no history of the disease.
Contact dermatitis
As the name suggest, contact dermatitis is an itchy rash caused by direct contact with an infectious substance or an allergic reaction to it. These substances may include plants, cosmetics or fragrances. The rash presents within days of exposure. The main symptom is a red rash where the skin come into contract with the irritant (Johansen et al., 2015). Additionally, rashes may develop, blisters, fissures, hives, peeing or ulcers. It is however presented with itching and swelling of the infected area. While some of the symptoms are similar with the patients’ he denies to have had food, environmental, latex, and drug allergies. Additionally, our patients presents symptoms which include; iritis, headache, pleurisy, malaise, myalgia, fever, photophobia, and pain surrounding the rash which is largely inconsistent with the symptoms of contact dermatitis. For that reason, contact dermatitis is not out primary diagnosis.
Cellulitis
Cellulitis is a bacterial infection of the subcutaneous tissue and the deep fascia. It occurs due to a breach of the skin that allows entry of the bacteria (Lindus, 2012). It is common in the extremities of the limbs. The symptoms are pain, erythema, swelling, warmth, chills, and malaise. The causes of cellulitis are streptococcus and staphylococcus aureus (Lindus, 2012). The patient has similar symptoms of fever and erythematous skin with tenderness. However, the diagnosis is not cellulitis because there are no skin rash and vesicular eruptions. Additionally, cellulitis is expected in the lower limbs.
Erysipelas
Erysipelas is a bacterial infection involving the upper dermis and the subcutaneous lymph tissues. It is characterized by erythema, tenderness, and indurated plague with sharply demarcated borders (Vandersee, 2019). It commonly occurs on the face or the legs. The presenting symptom is joint pain, nausea, fever, malaise, headache, and a skin lesion. This is not the patient's diagnosis because she has a skin rash at the back within a single dermatome.
References
Johansen, Aalto-Korte, K., Agner, T., Andersen, K. E., Bircher, A., Bruze, M., Cannavó, A., Giménez-Arnau, A., Gonçalo, M., Goossens, A., John, S. M., Lidén, C., Lindberg, M., Mahler, V., Matura, M., Rustemeyer, T., Serup, J., Spiewak, R., Thyssen, J. P., … Uter, W. (2015). European Society of Contact Dermatitis guideline for diagnostic patch testing - recommendations on best practice. Contact Dermatitis, 73(4), 195–221. https://doi.org/10.1111/cod.12432
Lindus. (2012). Cellulitis. Nursing Standard, 26(28), 59–59. https://doi.org/10.7748/ns2012.03.26.28.59.c8994
Nash, Humphries, F., Benjamin, L., & Werring, D. J. (2023). Varicella zoster vasculopathy associated with deep intracerebral haemorrhage. Journal of Neurology, 270(4), 2320– 2324. https://doi.org/10.1007/s00415-022-11537-6
Vandersee. (2019). Erysipelas carcinomatosum. Deutsches Ärzteblatt International, 116(1-2), 22–22. https://doi.org/10.3238/arztebl.2019.0022b
Yokota, Tamiya, A., Sahara, T., & Nakamura-Uchiyama, F. (2020). Adult Chickenpox. Internal Medicine, 59(15), 1923–1923. https://doi.org/10.2169/internalmedicine.4478- 20
