Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions

Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
Name
Institution
Date
Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
Comprehensive SOAP
Patient Initials: _CS______Age: ___43____Gender: ___M____
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA
Chief Complaint (CC):
The patient indicated had experienced rashes to his abdomen and chest (trunk).
History of Present Illness (HPI):
The 43 year old white male reported rash on his trunk and there are red papules/ lesions on his skin. This started 2 months ago, as brighter red patches or spots, but there is no itching. However, he denies that the papules are painful or there are any aggravating factors, but the papules have increased in size and number in the past two months.
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: No known allergies
Past Medical History (PMH):
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: Did not indicate risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
No history of smoking and tobacco use
Drinks wine weekly
No illicit drug usage
Not physically active, but eats healthy
Immunization History: Include
Last Tdp 2010
Last Flu vaccine 2018
Has not received pneumonia vaccine
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Mother has type 2 diabetes
Father has high blood pressure
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Middle class, college graduate, married with three sons
Review of Systems
General: There are no recent weight changes, weakness, fatigue, or fever
Neck: Normal range of motion and tracheal position in the right position,   patient uses glasses, no infection in the ear nose and throat.
Breasts: Negative for masses, tenderness, discharges and skin discoloration.
Respiratory: Normal respiration, the lungs are clear, and there is no cough or sputum
Cardiovascular/Peripheral Vascular: No chest pain, regular heart and rhythm, no edema and extra murmurs
Gastrointestinal: No abdominal pain, nausea or vomiting. There is daily bowel problems
Genitourinary: No incontinence, dysuria, discharge, incontinence, blood in urine and no STI
Musculoskeletal: No recent back pain, but there is pain on right hand and limited movement of the hand
Psychiatric: no mental/ psychiatric issue, no sleep problem, anxiety and depression