Last Updated on 08/07/2023 by Admin

Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP

Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
• Consider which of the conditions is most likely to be the correct diagnosis, and why.
• Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
• Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
• Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

The Lab Assignment

• 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.
• Week 4: Assessment of the Skin, Hair, and Nails

Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.

This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
• Consider which of the conditions is most likely to be the correct diagnosis, and why.
• Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
• Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
• Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

The Lab Assignment

• 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.
• Week 4: Assessment of the Skin, Hair, and Nails

Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.

This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.

Expert Answer and Explanation

Comprehensive Soap Note

Subjective Data 

Chief Complaint: “The client in image 1 complains of red patches in the feet, neck, and upper chest.

History of Present Illness:

Mrs. AD is a 60-years-old while male patient who presented today complaining of red patches in the feet, neck, cracked, and dry skin. The patient notes that his skin has been itching and dry for the past two weeks. The itching may often increase during the night. He also feels a lot of pain. When asked to state the level of her pain, he scaled it in a scale of 8/10. He reports that the red patches have affected his upper chest, neck, feet, and knees.

Medication:

Amlodipine 5mg/day PO and Hydrocortisone (OTC).

Allergies: No allergies. 

Past Medical History:  Well-controlled HBP.

Past Surgical History: Negative for surgery.

OB/GYN History: N/A

Personal/Social History: The patient drinks two beers a night and smokes three packets of cigarettes per week. He also wears seatbelt when in a car and does not use phones when driving.

Immunizations: He was immunized for tetanus three months ago. He also received pneumonia vaccine six moths ago.

Family History: Father died of diabetes at the age of 65 and mother died of heart attack at the age of 57. He has a sister and a brother. His sister was diagnosed with dementia and the brother is heathy.

Lifestyle: The patient likes swimming and watching movie during his free time. He also goes to the gym several times a week to improve his health.

Review of Systems

General: Negative for fatigue, fever, diarrhea, weight loss, or nausea.

HEENT: Negative for runny nose, sore throat, blurred vision, ear problem, cough, vision problems.

Respiratory: Negative for chest congestion, discomfort, pain or sputum.

CV: Negative for CV illnesses.

GI: Negative GI health issues.

GU: The patient is sexually active.

MS: Negative for MS conditions.

Integument/Heme/Lymph: The patient has dry, sore, cracked, and red patched skin.

Objective Data

Physical examination: The patient was seen scratching his skin and had a frowned face showing that he was feeling pain. During physical observations, red patches, sore, cracked skin on his upper chest, neck, feet, and knees.

Vitals: WH: 89 kg, He 161 cm, BP 142/92, HR 85, RR 20.

General: Dry, itchy, cracked, red patched skin.

 HEENT: Clear.

Neck: Clear.

Chest/Lungs: Clear.

Heart/Peripheral Vascular: High BP.

Abdomen: No rebound.

Musculoskeletal: Clear.

Skin: Dry, itchy, cracked, red patched skin.

Assessment

      Lab Tests: According to Davies et al. (2018), there are no existing laboratory tests for skin diseases. The disease is often diagnosed through physical examination.

      Diagnostics: Skin diseases can be diagnosed through physical examination and reviewing the patient’s medical history (Solman et al., 2019).

      Differential Diagnosis

1. Atopic Dermatitis– Atopic dermatitis is a skin condition that makes one’s skin becomes itchy and red (Solman et al., 2019). This disease has been selected as the primary diagnosis because the patient experiences the majority of the illness’ symptoms.
2. Psoriasis-This disease has been included in the diagnosis because it also causes itchy red scaly patches (Mehta et al., 2018).
3. Acne– Acne affects the skin by causing pimples, whiteheads, or blackheads and itchiness (O’Neill & Gallo, 2018). However, this disease has been ruled out because the patient does not have pimples.

References

Davies, E., Rogers, N. K., Lloyd‐Lavery, A., Grindlay, D. J. C., & Thomas, K. S. (2018). What’s new in atopic eczema? An analysis of systematic reviews published in 2015. Part 1: epidemiology and methodology. Clinical and Experimental Dermatology, 43(4), 375-379. https://onlinelibrary.wiley.com/doi/full/10.1111/ced.13377

Mehta, N. N., Shin, D. B., Joshi, A. A., Dey, A. K., Armstrong, A. W., Duffin, K. C., … & Menter, A. (2018). Effect of 2 psoriasis treatments on vascular inflammation and novel inflammatory cardiovascular biomarkers: a randomized placebo-controlled trial. Circulation: Cardiovascular Imaging, 11(6), e007394. https://doi.org/10.1161/CIRCIMAGING.117.007394

O’Neill, A. M., & Gallo, R. L. (2018). Host-microbiome interactions and recent progress into understanding the biology of acne vulgaris. Microbiome, 6(1), 177. https://link.springer.com/article/10.1186/s40168-018-0558-5

Solman, L., Lloyd‐Lavery, A., Grindlay, D. J. C., Rogers, N. K., Thomas, K. S., & Harman, K. E. (2019). What’s new in atopic eczema? An analysis of systematic reviews published in 2016. Part 1: treatment and prevention. Clinical and experimental dermatology, 44(4), 363-369. https://doi.org/10.1111/ced.13885

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FAQs

What are the four parts of a SOAP note?

In the context of medical documentation, a SOAP note refers to a standard format used by healthcare professionals to record patient information and observations. The four parts of a SOAP note are as follows:

1. Subjective (S): This section includes the patient’s subjective information, such as their chief complaints, symptoms, medical history, and any other information provided by the patient or their caregiver. It mainly focuses on the patient’s perspective and how they are feeling.
2. Objective (O): The objective section contains measurable and observable data obtained during the patient’s examination. It includes vital signs, physical examination findings, laboratory results, and any other relevant clinical data gathered by the healthcare provider.
3. Assessment (A): In this part, the healthcare provider analyzes and interprets the subjective and objective information to formulate a diagnosis or assessment of the patient’s condition. It involves the professional judgment and expertise of the healthcare provider.
4. Plan (P): The plan section outlines the treatment plan or course of action for the patient based on the assessment. It includes details such as prescribed medications, recommended therapies, further diagnostic tests, and follow-up appointments.

The SOAP note format ensures that healthcare providers maintain a structured and comprehensive approach to documenting patient encounters, facilitating effective communication and continuity of care.

How do you write a good SOAP note?

Writing a good SOAP note is essential for effective medical documentation and patient care. Follow these guidelines to create a well-structured and informative SOAP note:

1. Start with Patient Information: Begin the SOAP note by including the patient’s name, age, gender, and relevant identifying details.
2. Subjective (S):
   • Clearly state the patient’s chief complaints and any specific symptoms they are experiencing.
   • Document the patient’s medical history, allergies, and any relevant past medical or surgical procedures.
   • Include information provided by the patient or their caregiver regarding their current health status and concerns.
3. Objective (O):
   • Record objective data obtained during the physical examination, such as vital signs (e.g., blood pressure, heart rate, temperature).
   • Describe the results of any diagnostic tests, laboratory findings, and imaging studies.
   • Document specific physical findings, including observations related to the patient’s appearance, skin condition, and any palpable abnormalities.
4. Assessment (A):
   • Analyze the subjective and objective data to form a clear assessment of the patient’s condition.
   • Provide a concise summary of the patient’s diagnosis or differential diagnosis.
   • Use appropriate medical terminology and be specific in your assessment.
5. Plan (P):
   • Outline the treatment plan for the patient, including medications prescribed, dosages, and any other therapeutic interventions.
   • Specify any follow-up tests, consultations, or procedures scheduled for the patient.
   • Include patient education and instructions on managing their condition and medications.
   • Address any lifestyle modifications or recommendations to promote overall well-being.
6. Be Organized and Concise:
   • Use clear headings and subheadings to separate each section of the SOAP note.
   • Keep the note well-organized, logical, and easy to follow for other healthcare professionals.
7. Use Objective Language:
   • Write the SOAP note in a factual and objective manner, avoiding assumptions or personal opinions.
   • Use standardized medical terminology to ensure accuracy and clarity.
8. Be Thorough and Comprehensive:
   • Document all relevant information, including pertinent negatives (observations or symptoms that are absent).
   • Ensure that the SOAP note covers all aspects of the patient’s condition and care.
9. Follow HIPAA Guidelines:
   • Protect patient privacy and confidentiality by following the Health Insurance Portability and Accountability Act (HIPAA) guidelines.
10. Proofread and Review:

• Before finalizing the SOAP note, review it for accuracy, completeness, and any grammatical errors.

By following these guidelines, you can create a well-written and informative SOAP note that contributes to effective patient care and communication among healthcare providers.

HEENT SOAP Note

Patient Name: [Insert Patient Name]
Date of Evaluation: [Insert Date]

Subjective (S): The patient, a [insert age]-year-old [insert gender], presents today with the following chief complaints:

• [Insert chief complaint 1]
• [Insert chief complaint 2]
• [Insert any other relevant complaints or concerns expressed by the patient]

The patient reports a medical history of [insert relevant medical conditions] and allergies to [insert specific allergens].

Objective (O):

• Head: No signs of trauma or deformities. Normocephalic and atraumatic (NCAT).
• Eyes: Pupils equal, round, and reactive to light (PERRL). Extraocular movements (EOMs) intact. Visual acuity [if tested].
• Ears: Bilateral canals clear, tympanic membranes intact, no discharge or signs of infection.
• Nose: No septal deviation or nasal discharge observed. Sinuses non-tender to palpation.
• Throat: Oropharynx pink and moist. Tonsils [normal/size]. No erythema or exudates. No cervical lymphadenopathy.

Assessment (A): Based on the patient’s history and physical examination, the following assessments have been made:

• [Insert assessment 1]
• [Insert assessment 2]
• [Insert any other relevant assessments]

Plan (P): The following plan has been formulated for the patient’s care:

• [Insert treatment plan for assessment 1]
• [Insert treatment plan for assessment 2]
• [Include any medications prescribed, referrals made, or further diagnostic tests scheduled]
• [Insert patient education and instructions for self-care, if applicable]

Follow-up: The patient will schedule a follow-up appointment in [insert time frame] to monitor progress and make any necessary adjustments to the treatment plan.

Note: This SOAP note is a confidential medical document and is intended for use solely by authorized healthcare providers involved in the patient’s care. Patient privacy and confidentiality will be maintained in accordance with HIPAA guidelines.

Skin Rash SOAP Note

Patient Name: [Insert Patient Name]
Date of Evaluation: [Insert Date]

Subjective (S): The patient, a [insert age]-year-old [insert gender], presents with a chief complaint of a skin rash. The patient describes the rash as [insert characteristics, such as red, itchy, raised, etc.]. The rash first appeared [insert duration] ago and has [improved/worsened/ remained the same] since then. The patient reports experiencing mild to moderate discomfort and itching associated with the rash.

The patient denies any recent changes in skincare products, exposure to new allergens, or known contact with irritants.

Objective (O):

• Skin Examination: On visual inspection, there is a [insert size] [insert color and texture] rash located on [insert affected areas, e.g., arms, legs, trunk]. The rash is [insert distribution pattern, e.g., localized, scattered, generalized].
• Temperature: The skin around the rash is warm to the touch.
• Lesion Characteristics: The rash consists of [insert characteristics of the rash, such as papules, vesicles, erythema, etc.].
• Other Observations: No signs of infection, such as pus or drainage, are noted. No fever or other systemic symptoms reported.

Assessment (A): Based on the patient’s history and physical examination, the following assessment has been made:

• [Insert assessment of the skin rash, e.g., contact dermatitis, allergic reaction, eczema, etc.].

Plan (P): The following plan has been formulated for the patient’s care:

• Treatment: [Insert treatment plan, e.g., topical corticosteroid cream, antihistamines for itching, moisturizers, etc.].
• Avoidance: Advise the patient to avoid known allergens or irritants that may be triggering the rash.
• Patient Education: Educate the patient on proper skincare practices and the importance of avoiding scratching to prevent further irritation and potential infection.
• Follow-up: The patient will schedule a follow-up appointment in [insert time frame] to assess the progress of the rash and adjust the treatment plan if necessary.

Contact Dermatitis SOAP Note

Patient Name: [Insert Patient Name]
Date of Evaluation: [Insert Date]

Subjective (S): The patient, a [insert age]-year-old [insert gender], presents with a chief complaint of a skin rash, reporting that the rash appeared shortly after contact with a specific substance. The patient describes the rash as [insert characteristics, such as red, itchy, burning, etc.]. The rash is located on [insert affected areas, e.g., hands, arms, face, etc.]. The patient reports experiencing moderate to severe discomfort and itching associated with the rash.

The patient identifies the possible trigger as [insert potential irritant or allergen], to which they were exposed [insert time frame].

Objective (O):

• Skin Examination: On visual inspection, there is a well-demarcated, erythematous rash with edema and papules. The affected area is [insert size] and exhibits signs of inflammation.
• Lesion Characteristics: The rash consists of [insert characteristics of the rash, such as vesicles, bullae, weeping, etc.].
• Distribution: The rash is localized to the areas where the patient had direct contact with the potential irritant.
• Temperature: The skin around the rash is warm to the touch.
• Other Observations: No signs of infection, such as pus or drainage, are noted. The patient denies fever or other systemic symptoms.

Assessment (A): Based on the patient’s history and physical examination, the following assessment has been made:

• Contact dermatitis due to exposure to [insert suspected irritant or allergen].

Plan (P): The following plan has been formulated for the patient’s care:

• Treatment: Advise the patient to avoid further contact with the identified irritant or allergen. Prescribe a topical corticosteroid cream to reduce inflammation and itching.
• Cool Compress: Recommend cool compresses to alleviate discomfort and soothe the affected area.
• Antihistamines: Prescribe oral antihistamines to help relieve itching and promote better sleep.
• Moisturizers: Encourage the use of fragrance-free moisturizers to prevent dryness and maintain skin barrier function.
• Patient Education: Educate the patient on contact dermatitis triggers, proper skincare practices, and the importance of avoiding scratching to prevent worsening of the rash and potential infection.
• Follow-up: The patient will schedule a follow-up appointment in [insert time frame] to assess the progress of the rash and adjust the treatment plan if necessary.

SOAP Note with Differential Diagnosis

Patient Name: [Insert Patient Name]
Date of Evaluation: [Insert Date]

Subjective (S): The patient, a [insert age]-year-old [insert gender], presents with the chief complaint of [insert patient’s chief complaint]. The patient describes [insert characteristics of symptoms and any relevant medical history]. The onset of symptoms was [insert duration] ago, and the patient rates the severity of symptoms as [insert severity rating].

The patient denies any recent travel, exposure to sick individuals, or any significant changes in their daily routine.

Objective (O):

• Vital Signs: Blood pressure [insert mmHg], heart rate [insert bpm], respiratory rate [insert breaths per minute], temperature [insert °F/°C], oxygen saturation [insert %].
• Physical Examination: [Include findings from the physical examination, including specific observations related to the patient’s chief complaint].
• Laboratory and Diagnostic Tests: [Include relevant laboratory results, imaging findings, or other diagnostic test results].

Assessment (A): Based on the patient’s history, physical examination, and diagnostic test results, the following differential diagnoses have been considered:

1. [Insert differential diagnosis 1]
2. [Insert differential diagnosis 2]
3. [Insert differential diagnosis 3]
4. [Insert differential diagnosis 4]
5. [Insert differential diagnosis 5]

Plan (P): The following plan has been formulated for the patient’s care:

• Further Evaluation: Based on the differential diagnoses, further tests or consultations may be required to narrow down the diagnosis.
• Treatment: Initiate treatment for the most likely diagnosis while awaiting further test results, if appropriate.
• Medications: Prescribe medications, if necessary, to address the patient’s symptoms and provide relief.
• Patient Education: Educate the patient about the potential diagnoses, treatment options, and expected outcomes.
• Follow-up: Schedule a follow-up appointment in [insert time frame] to assess the patient’s response to treatment, review test results, and adjust the treatment plan accordingly.

Differential Diagnoses:

1. [Insert possible diagnosis 1]
   • [Include key features, symptoms, or findings supporting this diagnosis].
2. [Insert possible diagnosis 2]
   • [Include key features, symptoms, or findings supporting this diagnosis].
3. [Insert possible diagnosis 3]
   • [Include key features, symptoms, or findings supporting this diagnosis].
4. [Insert possible diagnosis 4]
   • [Include key features, symptoms, or findings supporting this diagnosis].
5. [Insert possible diagnosis 5]
   • [Include key features, symptoms, or findings supporting this diagnosis].

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