NURS-6512 Differential Diagnosis for Skin Conditions SOAP Note Essay

NURS-6512 Differential Diagnosis for Skin Conditions SOAP Note Essay

NURS-6512 Differential Diagnosis for Skin Conditions SOAP Note Sample EssaySUBJECTIVE DATA:

Chief Complaint (CC): ‘ I have a problem with my thumb’

History of Present Illness (HPI): A.A. is a 32-year-old client that came to the clinic for assessment. The patient came with complaints of having a problem with her finger nail. According to her, she started developing a midline split on her thumb three months ago. The client reported that she initially thought it would resolve on its own only for it to extend to the fingertip. The midline split has lines that run parallel to it. The patient denied any pain associated with the problem. She reported that the split does not interfere with her ability to perform her social and occupational activities. She was disturbed about its effect on her self-image. She has not used any medications in an attempt to treat the problem. 

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Medications:

The patient is currently not using any medications.

Allergies: The patient reported allergic reaction to pollen. She denied any drug, food, or medication allergies. 

Past Medical History (PMH): The patient has a history of hospitalization when she was 18 years due to anemia. She does not have any history of surgery. She has a history of blood transfusion. She denied any history of chronic illnesses, including her family.

Past Surgical History (PSH): The client denied any history of surgery.

Sexual/Reproductive History: The patient is married with one child. Her menarche was when she was 15 years. Her menstrual cycle is regular. Her last menstrual cycle was 20^th of this month. She does not have any problems related to her menstrual cycle. She does not use any contraceptive method. She denied any history of sexually transmitted infections or pregnancy loss. She also denied urgency, frequency, and dysuria

Personal/Social History: The client is married with one child. She works as a teacher. Her husband is a truck driver. She considers her family as her source of social support. She is a Christian and attends church always. She does not smoke, take alcohol or abuses drugs.

Health Maintenance: The patient reports that she engages in active physical activities thrice a week. She does not smoke, take alcohol, and abuses drugs. She wears a helmet while riding a bicycle. She underwent pap smear screening test two years ago, which was normal. She also utilizes screening services for conditions such as hypertension and obesity in her community.

Immunization History: Her immunization record is up to date.

Significant Family History: The client denied any history of chronic diseases such as cancer, hypertension, and diabetes in her family. She also denied any history of mental health illnesses in the family.

Review of Systems:

General: The client is alert and oriented to all facets. She is cooperative, maintains eye contact, and normal speech during the assessment. 

HEENT: The client denies current headache and history of head injury or acute visual changes. She reports no eye pain, redness, or dry eyes. Reports no change of hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, sinus pain, or pressure, or rhinorrhea. Denies any general mouth issues. She also denies dental concerns. She denies dysphagia, sore throat, voice changes, or swollen nodes.

Respiratory: The client reports normal breath, lack of wheezing, chest pain, dyspnea and cough.

Cardiovascular/Peripheral Vascular: The client reports no palpations, tachycardia, easy bruising or edema.

Gastrointestinal: The client reports no nausea, vomiting, pain constipation, excessive flatulence or diarrhea. She does not have food intolerance.

Genitourinary: She does not have dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching

Musculoskeletal: The client does not have muscle and joint pains whilst muscle weaknesses and swelling does not exist.

Neurological: She denies dizziness, tingling, light-headedness, seizures, loss of coordination or sensation, or sense of disequilibrium.

Psychiatric: Does not suffer depression, anxiety, or suicidal thoughts.

Skin/hair/nails: Reports the presence of a midline split in her left thumb that started three months ago. Denies hair loss, skin dryness or cracking.

OBJECTIVE DATA:

Physical Exam:

Vital signs:  Height: 160m cm Weight: 72 Blood glucose8 HR: 78 BP: 118/72 Pulse Ox: 99% Temperature: 99.0 F

General: The patient is alert and oriented to all facets. She sits upright on the examination table. She has good health.

HEENT: Head is normocephalic and atraumatic. The eyes are bilateral eyes with equal hair distribution on lashes and eye brows. Eye lids do not have lesions. There is no ptosis or edema. Conjunctiva appears pink with no lesions and white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen assessment results: 20/20 right eye, 20/20 left eye. Tympanic membranes intact and pearly gray bilaterally with positive light reflex. The client hears whispered words bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact. Dentation do not show evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. There is no lymphadenopathy.

Neck:

Chest/Lungs: Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout.

Heart/Peripheral Vascular: Hear rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.

Abdomen: Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly and CVA tenderness.

Genital/Rectal: Not assessed

Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. There is no pain with movement.

Neurological: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Deep tendon reflexes 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Nails: The thumb nail is split at the midline with lines parallel to the main groove. The split extends to the fingertip. The capillary refill is less than three seconds bilaterally.

Diagnostic results: none

ASSESSMENT: The client’s primary diagnosis is median nail dystrophy. Median nail dystrophy is a condition characterized by the split in the midline of the nail. It largely affects the thumb in a longitudinal version towards the edge of the fingernail. The problem arises from issues in the matrix of the nails. In addition, factors such as infection or injury affecting the nailbed cause it (Khodaee et al., 2020). The other potential diagnosis that may be considered is subungual tumor. Subungual tumors affect the nailbed and characterized by pain and striations that begin at the nail fold. The absence of pain and single midline makes subungual tumor the least likely cause of the client’s problem (Hinchcliff & Pereira, 2019). The last diagnosis to be considered is melanonychia. Melanonychia is a condition characterized by nail discoloration (Singal & Bisherwal, 2020). However, there is no midline splitting of the nailbed as seen in median nail dystrophy.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

References

Hinchcliff, K. M., & Pereira, C. (2019). Subungual Tumors: An Algorithmic Approach. The Journal of Hand Surgery, 44(7), 588–598. https://doi.org/10.1016/j.jhsa.2018.12.015

Khodaee, M., Kelley, N., & Newman, S. (2020). Median nail dystrophy. CMAJ, 192(50), E1810–E1810. https://doi.org/10.1503/cmaj.201002

Singal, A., & Bisherwal, K. (2020). Melanonychia: Etiology, Diagnosis, and Treatment. Indian Dermatology Online Journal, 11(1), 1–11. https://doi.org/10.4103/idoj.IDOJ_167_19

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