Skin Comprehensive SOAP Note

 

Patient Initials: D.O.             Age: 57 years                         Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): Pain and swelling.

History of Present Illness (HPI): D.O. is a 57-year-old Caucasian female who presents with pain and swelling on her right leg for the past two weeks. She reports that she doesn’t recall experiencing any trauma on her right leg. She remembers experiencing pain and swelling in her right leg, which progressively became red and tender. Later on, she noticed an ulcer on her right leg. D.O. rates the pain on a scale of eight out of ten. She explains that the pain limits her movement and worsens when she tries to walk. She bought an over-the-counter cream whose name she doesn’t recall and paracetamol tablets. The cream and pills temporarily relieved the pain and swelling. D.O. highlights that she has been experiencing fever and fatigue intermittently for the past week.

Are you interested in obtaining help on your assignment ? Reach out to us.

Medications:

Paracetamol 1000mg TDS PRN

Metformin 500mg BD

Glibenclamide 10mg BD

Allergies: No known drug allergy. No known food allergy.

Past Medical History (PMH): She has been a known diabetic for the past twenty years, which she manages by taking metformin and glibenclamide.

Past Surgical History (PSH): Caesarian section (1995).

Sexual/Reproductive History: Heterosexual.

Personal/Social History: She occasionally takes alcohol and has not smoked cigarettes for the past twenty-seven years.

Immunization History: Her immunization is up to date. She was vaccinated for COVID-19 on 30/11/2021 and 1/1/2022.

Significant Family History: D.O. has two 26-year-old male children who are twins. Her sons are alive and healthy. D.O. is the second born of three children. She has two brothers. One of her brothers is active and healthy, while the firstborn is a known diabetic and hypertensive. D.O.’s mother died from breast cancer, while her father died from diabetes complications. Her paternal grandparents died of diabetes. Her maternal grandmother died of diabetes, while her maternal grandfather died of prostate cancer.

Lifestyle: D.O. is married. She lives with her husband in her own compound house in the suburbs. She was a primary school teacher and took early retirement two years ago to focus on farming. She spends most of her days on the farm with her employees. She maintains a healthy lifestyle by staying active, taking daily walks, and eating a balanced diet. She has comprehensive health insurance.
 Review of Systems:
General: The patient reports fever and fatigue. She denies chills, headaches, night sweats, day sweats, daytime sleepiness, sleep disturbances, weight gain, or weight loss.

HEENT/Neck: The patient denies difficulty swallowing and rhinorrhea. She refuses double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Also, she refuses changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. She also refuses dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion. Her last eye and dental examination were six months ago.

Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.

Cardiovascular/Peripheral Vascular: Reports swelling on the right leg. Denies lightheadedness when standing, paroxysmal nocturnal dyspnea, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies painful urination, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine.

Musculoskeletal: The patient has been experiencing pain in her right leg. She denies muscle pain, stiffness, or joint pain.

Neurological: Denies memory loss, changes in memory, loss of consciousness, seizures, confusion, difficulty balancing, numbness, tingling sensation, changes in thinking patterns, spells of blindness, or dizziness.

Psychiatric: Denies history of suicidal thoughts, depression, anxiety, bipolar disorder, or any other mental health problem.

Skin: Reports swelling, redness, tenderness, and ulceration on her right leg.

Endocrinology: Denies weight gain, hair loss, hot flashes, weight loss, and frequent urination.

Reproductive: Heterosexual. Sexually active with one partner.
 OBJECTIVE DATA:
Physical Exam:

Vital signs: BP 139/80 mmHg, HR-72 bpm, SPO2- 98% on room air, Temp 98.3, RR-18 bpm, Height- 163cm, Weight- 77kgs, BMI 29.

General: The patient is cooperative, hygienic, and well-dressed. She appears to be in a lot of pain.

HEENT: Clear or nasopharynx, PERRLA, normocephalic head, no visual acuity issues.

Neck: The neck has a full range of motion in all directions, normal symmetry, standard length, and no palpable lymph nodes.

Respiratory: On palpation, there is no tenderness or palpable mass. On auscultation, normal breathing sounds without wheezing or audible breathing sounds—no chest deformities.

Heart/Peripheral Vascular: On palpation, average heart size and standard heart location. On auscultation, average heart rate, regular rhythm, and no murmurs. Normal extremities.

Abdomen: Denies abdominal pain on palpation. The liver and spleen are of average size and have normal tenderness and consistency.

Genital/Rectal: The patient declined this exam.

Lymphatic: No swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Psychiatric: Normal mood, memory, awareness of context, and orientation to time and place,

Skin: Her skin tone is appropriate for her ethnicity. Her right leg is swollen with a visible ulcerated area. The skin has erythema and is warm and painful to the touch.
 Diagnostic results:
ASSESSMENT:
Fasting blood sugar test: D.O. is a known diabetic, which is a risk for slow wound healing (Sapra & Bhandari, 2022). The results showed an average fasting blood glucose of 80mg/dL.

Complete blood count: Recommended to determine infection and system toxicity level.

CT scan: Recommended to detect necrotizing soft tissue infections.

Diagnosis according to the presenting complaint and history of the presenting complaint is primarily based on the history and physical findings.

C-reactive protein value: Recommended to evaluate the extent of inflammation.

Hepatic function tests: These are recommended to confirm hepatic function and rule out renal failure.

Differential Diagnosis (DDx):

Cellulitis: Cellulitis occurs after a breach in the skin, which is worsened by an acute infection. D.O.’s daily routine includes farm work, where thorns and other plants can prick her. Patients diagnosed with cellulitis usually present with pain, swelling, erythema, and leg warmth (Brown & Hood, 2022). D.O. presents with redness, warmth, pain, and swelling on her right leg. She has visible ulceration, which is a sign of skin breach. Patients with diabetes mellitus are prone to severe cellulitis and recurrent cellulitis. The foot and lower extremities are the most vulnerable body parts for people with diabetes. D.O.’s chief complaint affects her right leg. Diabetic patients experience slow wound healing, which might alter the healing of the ulcer on D.O.’s leg. D.O. is a known diabetic; therefore, cellulitis is a differential diagnosis. Complete blood count results and fever are signs of an infection.

Erythema multiforme: Patients diagnosed with erythema multiforme present with a fever, diarrhea, chest pains, sore throat, rash, and pruritis on the extremities (Hafsi & Badri, 2021). It is a skin condition that is caused by infections. D.O. presents with a fever, which is a sign of infection. Diagnosis is conducted with a physical examination of a lesion. However, D.O. has an ulcer on her right leg. It does not present as a lesion in erythema multiforme with variable mucous membrane involvement.

Gas gangrene: Gas gangrene is caused by Clostridium perfringens infection (Buboltz & Murphy, 2022). D.O. presents with a fever, which is a sign of an infection. Patients diagnosed with gas gangrene present with pain and swelling, and the affected area turns blue-black or bronze. D.O.’s right leg is painful, swollen, and red. A physical examination of the affected leg and color rules out gas gangrene as a diagnosis.

Calciphylaxis: Long-term obesity is a risk factor for calciphylaxis (Westphal & Plumb, 2022). It is a differential diagnosis since D.O.’s BMI shows that she is obese. Chronic renal failure is the leading cause of calciphylaxis. Patients diagnosed with calciphylaxis present lesions mainly on the lower extremities (Westphal & Plumb, 2022). D.O. presents with an ulcer on her right leg. Renal function test results are expected and rule out calciphylaxis as a diagnosis.

Acute febrile neutrophilic dermatosis: Patients diagnosed with acute febrile neutrophilic dermatosis present with fever and lesions. D.O. presents with fever, as seen in acute febrile dermatosis. The lesions are violet, bright red, or reddish-blue. D.O.’s ulcer, on physical examination, does not present as an acute febrile neutrophilic dermatosis (Majmundar & Baxi, 2022).

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be needed for future classes.
References
Brown, B.D., & Hood Watson, K.L. (2021). Cellulitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549770/ 

Buboltz, J.B., & Murphy-Lavoie, H.M. (2022). Gas Gangrene. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537030/

Hafsi, W., & Badri, T. (2021). Erythema Multiforme. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470259/