Skin Comprehensive SOAP Note Template
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. Skin Comprehensive SOAP Note Template
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: MN Age: 39 Gender: F
SUBJECTIVE DATA:
Chief Complaint (CC): Hot, painful, and swollen skin.
History of Present Illness (HPI): MN is a female patient who presents to the clinician with a complaint of hot, swollen, and painful blistered skin near the toes and the back of the lower legs. The extent of the pain is rated at 7 out of 10. Related complaints include skin tenderness and redness. Patient reports the symptoms began showing three days ago. Patient reports having the urge to squeeze the pus out of the swelling.
Medications: OTC Benefiber, OTC Ibuprofen 200mg -2 PO, Lisinopril 10mg QD
Allergies: Sulfa drugs – rash
Past Medical History (PMH): Gastroesophageal reflux (GERD), Hypertension – under control
Past Surgical History (PSH): No surgical history
Sexual/Reproductive History: Heterosexual, Last menses 5 June 2022
Personal/Social History: Lives with husband, No smoking history; No ETOH or illicit drug use.
Health Maintenance: Has a healthy diet and eating pattern. There are resources and community groups for athletics which she attends weekly. She enjoys swimming. Reports a healthy support system comprising family and friends.
Immunization History: Up-to-date immunizations. influenza vaccine last September 2021, Covid-19 vaccine March 2021, and Pneumococcal vaccine January 2022
Significant Family History: Two elder siblings in their forties– one with asthma, dx at age 42, and the other with hyperlipidemia, dx at age 42. Two teenage daughters, healthy, school-going.
Review of Systems:
General: No fever, chills or night sweats; no recent significant weight gains or losses
HEENT: No changes in vision or hearing; no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. no recent ear infections, tinnitus, or discharge from the ears. Normal sense of smell. No epistaxis. No history of nasal polyps or recent sinus infection. No ulceration, lesions, gingivitis, and no dental appliances. Chewing or swallowing normal.
Respiratory: No hemoptysis, no difficulty breathing at rest; + dyspnea on exertion. Last PPD 2021. Last CXR – 2021.
Cardiovascular/Peripheral Vascular: No palpitations, chest discomfort, history of murmur; No history of arrhythmias, orthopnea, dyspnea, oedema, or claudication. Last ECG/cardiac workup May 2021.
Gastrointestinal: No nausea or vomiting. No abdominal pain, no changes in bowel/bladder pattern. Uses fibre as laxative for constipation.
Genitourinary: Heterosexual. No dysuria, or incontinence. No history of STDs or HPV. Sexually active.
Musculoskeletal: No arthralgia/myalgia, arthritis, gout or limitation in range of motion. No history of fractures or trauma.
Neurological: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory; no twitches or abnormal movements; no history of gait disturbance. No falls or seizure history.
Psychiatric: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history.
Skin/hair/nails: Lower extremeity tenderness, rash, tenderness, redness, warmth, and swelling. Lotion for dry skin. No history of skin cancer or lesion. Skin Comprehensive SOAP Note Template
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OBJECTIVE DATA:
Physical Exam:
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 100 F; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21
General: Well-nourished, Well-appearing, concerned. Oriented x 3, affect and mood normal. Normal ambulation.
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, normal fundi, no haemorrhages or exudates.
Ears: EACs clear, hearing, ossicles, and appearance intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
Mouth: Moist mucous membranes, mucosal lesions absent.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple; No bruits, adenopathy; Normal thyroid
Chest/Lungs: Clear to auscultation and percussion
Heart/Peripheral Vascular: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Abdomen: Normal bowel sounds; no tenderness, organomegaly, or hernia
Genital/Rectal:
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, atrophy or abnormal strength or tone in the head, neck, spine, or extremities
Neurological: CN 2-12 normal. Normal sensation to pain, touch, and proprioception. DTRs normal in either extremity. Pathologic reflexes absent.
Skin: Good turgor; Rash, tenderness, redness, unusual bruising, prominent lesions.
Diagnostic results: WBC 15,000, SAO2 – 98%,
ASSESSMENT:
Definitive Diagnosis: Cellulitis is characterized by infection of the deep dermis and subcutaneous tissue. Cellulitis tends to be pinker, mildly erythematous, and flat with less distinct boundaries (Brown and Watson, 2021). Skin Comprehensive SOAP Note Template
Differentials
Erysipelas is more superficial and affects the epidermis and superficial lymphatic system. Symptoms include elevation of the affected skin, erythema, redness, and well-demarcated borders. Superficial cases are characterized by streaking (Brown and Watson, 2021).
Chronic venous stasis dermatitis is characterized by the appearance of the lower extremities and symptom manifestation similar to erythema with peripheral edema, scaling, and hyperpigmentation (Sundaresan et al., 2017).
Necrotizing fasciitis causes necrosis of the subcutaneous tissue and is typified by erythema, fevers, pain, edema, and crepitus (Wallace and Perera, 2021).
Deep venous thrombosis is common in the lower extremities and presents with the rhythm attendance warmth and oedema (Stone et al., 2017).
References
Brown, B. D., & Watson, K. L. H. (2021). Cellulitis. In StatPearls. StatPearls Publishing.
Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovascular diagnosis and therapy, 7(Suppl 3), S276–S284. https://doi.org/10.21037/cdt.2017.09.01
Sundaresan, S., Migden, M. R., & Silapunt, S. (2017). Stasis Dermatitis: Pathophysiology, Evaluation, and Management. American journal of clinical dermatology, 18(3), 383–390. https://doi.org/10.1007/s40257-016-0250-0
Wallace, H. A., & Perera, T. B. (2021). Necrotizing Fasciitis. In StatPearls. StatPearls Publishing.
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Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
