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SOAP NOTE Differential Diagnosis for Skin Conditions Skin Condition Picture # 3 Patient Initials: J, M Age: 48 Gender: Male SUBJECTIVE DATA: Chief Complaint (CC): Open lesion to the left side of the cheek. History of Present Illness (HPI): James Moleli, a male aged 48 years, was brought to the clinic by his wife. He has complained of lesions on the left cheek, redness with posture, and hair. The red lesions developed a month ago; initially, a pimple kept on growing. The patient has reported irritation, itching, and pain. Mr. Moleli states he has been trying the over-the-counter cream and pain medication but is getting worse. He stated that he has missed work for a week due to the localization of the lesion, which makes him embarrassed to be in public. Medications: 1.) lisinopril 5mg daily 2.) metformin 500mg BID 3.) Motrin 400mg once a day 4.) Lantus 15 units QHS Allergies: NKDA Past Medical History (PMH): 1. Hypertension 2.) Diabetic Past Surgical History (PSH): NONE Sexual/Reproductive History: Married for 23 years with three kids ages 20, 17 and 15 Personal/Social History: He has never smoked Denied ETOH or illicit drug use He lives in a very nice neighborhood and is active in his community and church. He works in a pharmaceutical company as a supervisor. The wife is a high school teacher. His firstborn is in a pharmacy school, second born is a college and last born is still in high He is financially stable. Immunization History: The COVID-19 Vaccine is currently updated with two boosters. Influenza Vaccination current He is current with all vaccines recommended based on age and health risk factors. Significant Family History: Never knows his biological parents or siblings as he was raised by foster parents who are pastors. He left his foster parentâ€™s house after getting married 23 years ago. He has a good relationship with his foster parents and still keeps in touch with them. Review of Systems Objective Data General: The patient is alert and oriented x4, well-nourished, hydrated, and well-groomed. he is comfortable talking about his medical history. HEENT: Skull normocephalic and atraumatic Sparse hair with balding Ear: No hearing problem, no drainage noted Eye: PERRLA Nose: clean no rhinorrhea. Throat: No swelling, noted, and Able to swallow without any problem. Chest/Lungs: no emasculation in all lung fields. The chest rises and falls symmetrically. Breast: Normal for men with no signs of masses or gynecomastia Neck: Has full range motion and no carotid or masses detected. Heart/Peripheral Vascular: Heartbeat is regular rate and rhythm with no murmur. Abdomen: There is the presence of bowel sounds at x4 quadrants. The abdomen is soft, non-tender, and non-distended. There is an absence of organomegaly. Skin: Left side of the cheeks with excessively grown hair reddish. The patient has reported itching and irritation in the affected area. Vital signs: B/P 144/98; T 99.9 Tempol, RR 16; Wt: 180 lbs.; Ht: 5â€™11; BMI 25 FSBS 146mg/dl. Lab Tests: The following tests can be conducted to confirm the diagnosis and rule out other possible conditions. 1. Skin culture 2. Complete Blood count (CBC) 3. Glycated hemoglobin (AIC) 4. Comprehensive metabolic panel (CMP) ASSESSMENT: Priority Diagnosis: folliculitis Differential Diagnoses: 1. Furuncles 2. impetigo 3. carbuncles 4. Atopic Dermatitis. Explanation of the diagnosis Based on the subjective and objective data provided, the priority diagnosis for Mr.Moleliâ€™s skin condition is folliculitis. It is a common hair follicle infection that is generally benign (Winter & Mitchell, 2022). The hair follicles become inflamed and forms pustule on the overlying skin (Winter & Mitchell, 2022). Mr. Moleliâ€™s skin problem is evidence of folliculitis due to the appearance of the lesion. The disease occurs in the areas of the body where hair grows such as the face, neck, scalp, or even thighs (Winter & Mitchell, 2022). The disease can be caused by viruses, fungi infections, bacteria, or even parasites that are common when there is poor hygiene, skin irritation, shaving, and wearing very tight clothes (Acne-like breakouts could be folliculitis). In Mr. Moleliâ€™s case, the lesion on his left cheek with excessive hair growth, redness, and the presence of pustules is consistent with a folliculitis diagnosis (Acne-like breakouts could be folliculitis). The lesion starts as a pimple and then keeps on growing is typical of folliculitis. He also reported experiencing irritation, itching, and pain which are common symptoms of the disease. The failure of the over-the-counter creams to contain the infection further supports the diagnosis. The management of folliculitis is dependent on its severity and underlying cause. The goals are to contain the infection and reduce inflammation in the affected area. Warm compresses can be used on the cheek to soothe the skin and relieve pain and itching (Rambhia et al., 2019). With the diagnosis confirmed, Mr. Moleli can prescribe topical antibiotics to be applied directly to the affected area. Mr. Moleli is to be advised by the health provider to keep the affected area clean and dry and avoid the right clothes (Rambhia et al., 2019). It is also important that a follow-up is done to monitor the condition and ensure the given treatment is working. References Acne-like breakouts could be folliculitis. American Academy of Dermatology. (n.d.). Retrieved March 24, 2023, from https://www.aad.org/public/diseases/a-z/folliculitis Rambhia, P. H., Conic, R. R., Murad, A., Atanaskova-Mesinkovska, N., Piliang, M., & Bergfeld, W. (2019). Updates in therapeutics for folliculitis decalvans: a systematic review with evidence-based analysis. Journal of the American Academy of Dermatology, 80(3), 794-801. Winters, R. D., & Mitchell, M. (2022). Folliculitis. In StatPearls [Internet]. StatPearls Publishing. Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: Â· Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). Â· Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a different diagnosis of three to five possible considerations for the skin graphic. Â· Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a â€œreally bad sore throatâ€ made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Childrenâ€™s Motrin which made his fever better but did not help sore throat. He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue.