Comprehensive SOAP Note for Skin Conditions Discussion

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Comprehensive SOAP Note for Skin Conditions Discussion

Comprehensive SOAP Note for Skin Conditions: Tinea Barbae (Barber’s Itch)

Patient Initials: ___L.M.____             Age: ___46 years____            Gender: ___M____

SUBJECTIVE DATA:

Chief Complaint (CC): “I have had a scaly, round, itchy, slightly painful rash under my beard that resembles ringworm for the past fortnight.”

History of Present Illness (HPI): The 46-year-old male Caucasian client has never had the manifestations that are bothering him now (Photo number 3). The area of involvement is on the left side of the face, in the beard, and the signs started a fortnight ago. The area affected is painful, scaly, and itchy, and the symptoms have persisted throughout. Hot weather exacerbates the symptoms, which can be somewhat alleviated by cleansing the region. The individual ranks their level of discomfort at 5 out of 10, with symptoms occurring day and night.  Comprehensive SOAP Note for Skin Conditions Discussion

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Medications:

  • Clotrimazole cream applied TDS (OTC).
  • Paracetamol 500 mg PRN (OTC).

Allergies: NKDA.

Past Medical History (PMH): There are no recognized long-term medical issues affecting him. However, he had previously been diagnosed with community-acquired pneumonia and admitted to the hospital.

Past Surgical History (PSH): Denies past surgical history.

Sexual/Reproductive History: He identifies himself as heterosexual. He is married for 18 years and has two teenage children.

Personal/Social History: The individual in question holds a Master’s degree and works as a college instructor. He frequently goes out for drinks after work with a select group of his closest companions. He merely takes small doses of alcohol practically every day. But he periodically indulges in excessive drinking, particularly over the weekends. He does not take drugs or smoke. He never uses his phone while driving and always fastens the seat belt. Swimming, adventuring, boating, and watching football are some of his pastimes.  Comprehensive SOAP Note for Skin Conditions Discussion

Health Maintenance: He regularly takes his family to the eye, dental, and ENT offices for exams every six months and once a year.

Immunization History: As a child, he received all of his vaccines. In addition to receiving the adult flu and pneumonia vaccinations, he has received booster DTap dosages. He received in 2021 two Covid-19 vaccine doses after the worldwide pandemic began.

Significant Family History: Neither his father’s nor his mother’s side of the family has a noteworthy history of chronic illness.

Review of Systems:

General: Denies fever, headaches, malaise, chills, and weight loss.

HEENT: Negative for double vision, tinnitus, sneezing, or dysphagia.

Respiratory: Negative for DIB, coughing, wheezing, and sputum.

Cardiovascular/Peripheral Vascular: Denies chest tightness/ pain, palpitations, or peripheral edema. Comprehensive SOAP Note for Skin Conditions Discussion

Gastrointestinal: Negative for N/V/D or a change in bowel habits.

Genitourinary: Denies frequency, dysuria, or discharge.

Musculoskeletal: Negative for back pain, myalgia, or arthralgia.

Neurological: Denies dizziness, fainting, pins and needles, or loss of bowel and bladder function.

Psychiatric: Denies anxiety or depressive manifestations.

Skin/hair/nails: Negative for itching, rash, or eczema (Ball et al., 2019).

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 128/80 mmHg; P 72 bpm; T 98.6 °F; RR 15; BMI 25.9 kg/m2       (slightly overweight).

General: The client is conscious and aware of the time, place, people, and activities around them. He has a rational, goal-oriented style of speaking. He is groomed and clothed according to the weather and time of day.

HEENT: Both PERRLA, EOMI. Nasal turbinates are not inflamed. The tympanic            membranes demonstrate appropriate light reflex. The throat is not erythematous.

Neck: Absent lymphadenopathy, no jugulovenous bulging.

Chest/Lungs: The lung fields are clear on both sides.

Heart/Peripheral Vascular: HSs 1 & 2 are RRR with no murmurs. Capillary refill is < 3            sec.

Abdomen: Upon inspection, there is no edema or distension. There is nothing special       about percussion. There is no discomfort or guarding when palpated. Additionally,          organomegally is absent. There are audible bowel sounds on auscultation.

Genital/Rectal: The genitalia do not have any noticeable lesions. Enlargement of the       prostate is not detected during the rectal exam. Comprehensive SOAP Note for Skin Conditions Discussion

Musculoskeletal: All limbs have normal strength of muscles and sensitivity.

Skin: On the left side of the beard, there is a sizable lesion that is hair-covered. It has       scales and is round.

Diagnostic results:

  • The blood count shows normal results.
  • Metabolic profile shows some dyslipidemia (Hammer & McPhee, 2018).

ASSESSMENT:

  1. Tinea Barbae (Dermatophytosis) or Barber’s Itch

Skin, hair, and nails are keratinized tissues that are infiltrated by fungi called dermatophytes. The disease known as dermatophytosis, or “tinea” infections, is caused by dermatophytes. Dermatophytes do not infect mucosal surfaces because they are keratinophilic and need keratin to grow. Dermatophytes can infect any superficially keratinized area, including the scalp and toes (Kuruvella & Pandey, 2023). The location of the affected body dictates the classification of tinea infections. The skin, hair, and hair follicles of the mustache and beard are affected by a rare dermatophyte illness known as tinea barbae (Hammer & McPhee, 2018; Jameson et al., 2022). The lesion is often scaly, itchy, and mildly painful. Comprehensive SOAP Note for Skin Conditions Discussion

  1. Bacterial Folliculitis

This common variation resembles an itchy rash of pus-filled lesions. It occurs when hair follicles become infected with bacteria, most frequently Staphylococcus aureus (staph). On the epidermis, Staph bacteria are always present (Hammer & McPhee, 2018; Jameson et al., 2022). They can also be dangerous if they enter the body through a cut or other wound.

  • Contact Dermatitis

Contact dermatitis is a condition that causes an itchy rash as a result of an allergic reaction to an allergen or direct touch with it. The rash is not contagious, but it can be very unpleasant. Numerous items, such as jewelry, plants, perfumes, and cosmetics, might trigger this reaction (Hammer & McPhee, 2018; Jameson et al., 2022). The rash usually occurs days after contact. Comprehensive SOAP Note for Skin Conditions Discussion

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References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2022). Harrison’s principles of internal medicine, 21st ed. McGraw-Hill Education.

Kuruvella, T., & Pandey, S. (2023, June 25). Tinea barbae. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK563204/ Comprehensive SOAP Note for Skin Conditions Discussion

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 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. Comprehensive SOAP Note for Skin Conditions Discussion
NOTE BELOW:
I WILL UPLOAD THE FOLLOWING DOCUMENTS:
1. These Instructions
2. The Skin Condition Document (which can also be downloaded from the above required reading)
3. Comprehensive SOAP exemplar (which can also be downloaded from the above required reading)
4. Comprehensive SOAP Template (which can also be downloaded from the above required reading) Comprehensive SOAP Note for Skin Conditions Discussion