JK with Itchy Skin Lesions Soap Note

JK with Itchy Skin Lesions Soap Note

SUBJECTIVE DATA

Patient initials: JK

Age: 42 years

Gender: Male

Chief Complaint – Itchy skin lesions for 8 weeks (seen in graphic 1)

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History of Presenting Illness

Jack Kyle, 42 year old male, presented to the facility today with multiple itchy purplish skin lesions since 8 weeks ago on his left hand. They were of sudden onset around the wrist region but have gradually been increasing in size and number thus covering the whole hand. Same patches started forming around his genital area. He reported that he was taking Quinine and ibuprofen when he fast noticed a rash on his skin that later developed to this patches. Rubbing on the patches using a soft cloth provided some short term relief. No history of a scratch. Over the last one week he started having pain on his left hand. Taking paracetamol provided short time relief for about 2 hours. There is associated hair loss where the patches are forming. No history of trauma

Medications

  • Enalapril 10mg occasionally, sometimes forgets to take
  • Paracetamol 500mg when needed
  • Ribavirin 1000mg daily
  • Peginterferon alfa 2 daily
  • Propranolol 80 mg daily

Allergy

He reports allergy to red meat

No history of drug allergy

Past medical history

Hypertension-not well controlled

Hepatitis C – Recently diagnosed, reports compliance to medication

He is seronegative, last tested June this year 2020

Past surgical history

Had kidney transplant secondary to chronic renal failure 2018

No history of blood transfusion

Family social history

His mother who is diabetic was diagnosed with Lichen planus

His father who died from lung cancer complications also had skin disease that he could not recall

He smokes 3 pack of cigarettes every day for 15 years

He has taken alcohol for 10 years

Lifestyle

He is a father, married, with 3 children. He works in metal refining industry. Reports exposure to chemicals at work. He has a medical insurance cover. Does not adhere to daily meal intake.

Review of system

HEENT: Reports reduced hearing in the past 3 weeks ago with no ear infection nor discharge, no changes in vision. No history of epistaxis and allergic rhinitis. He denied gum bleeding, has poor oral health with discolored teeth, no gingival swelling, no dental appliances. He reports mild pain on swallowing food.

Neck – No masses, pain, injury or difficulty in moving the neck.

Respiratory – cough that is productive, no hemoptysis, difficulty in breathing or dyspnea

CVS- no breathlessness, chest pain, orthopnea, or paroxysmal nocturnal dyspnea. He has palpitation at rest.

GI-He has no nausea, vomiting, diarrhea, constipation, abdominal pain or loss of appetite

GU– no urinary incontinence, hesitancy, dysuria, dribbling or increased frequency f urination; There is history of reduced urine stream. No history of sexually transmitted infection

Musculoskeletal system – no joint pain or swelling, no muscle pain; No history of trauma; Reports reduced range of motion

Psych-No sleep disturbance, no anxiety. Reports incidences of depression due to wasting all his money on alcohol and cigarettes without saving.

Central nervous system: no headache, dizziness, confusion, or change in the thinking process. No history of convulsion and seizures. No change in gait or disturbed coordination.

Endocrine-no history of hormonal imbalances or abnormal endocrine symptoms. No use of hormonal therapies.

Allergic/Immunologic – not immunodeficient, allergic to red meat. Had an organ transplant in 2018

Objective Data

Physical exam:

General: Sick looking, not in respiratory distress, no scleral jaundice, no conjunctival pallor, no central cyanosis

Vital signs: B/P 183/97mmHg, P 82bpm regular rhythm, good volume, temperature 99.4 F, RR 18bpm, non-labored, WT 150lbs, HT 5`7, BMI 23.5

HEENT – Discolored teeth, poor oral health, flexible temporo- mandibular joint, no facial masses, and small white plaques in the buccal cavity.

Neck- no masses, JVP not raised, no tenderness

CNS – Oriented to person, place and time, GCS at 15/15, all cranial nerves normal except for slight derangement in vestibulocochlear nerve

Respiratory system-No tracheal deviation, chest moves with respiration, resonant, vesicular breath sound heard, no tenderness

CVS – S1, S2 heard, no murmur, pulse of good volume and rhythm. No added heart sound. Apex beat at midclavicular line 5th intercostal space.

Abdomen: Non distended, no splenomegaly, no tenderness, moves with respiration, no distended veins, hepatomegaly of 4 cm below the coastal margin.

Genital/rectal – genitals clean. Multiple purplish patchy lesions around the genital area, pubic hair lost, no puss.

Musculoskeletal system-normal muscle bulk, reduced tone, muscle power at 5/5 for both limbs

Skin/lymph – multiple purplish, flat toped, shiny, different sized, polygonal-shaped skin lesions distributed along the left hand, extending from palm to shoulder. Similar patches are in the genital area. Not oozing pus.

Assessments

Laboratory tests and results

Complete blood count – Hb 10.1g/dl, white blood cells 12,000 per microliter of blood, platelets 180,000

Urinalysis-leucocytes present

Diagnostics

Patch test – Negative

Skin biopsy – shows hyperkeratosis with prominence of granular layer and band like infiltrate along the dermo-epidermal junction hence destroying the basal layer of the epithelium

Differential diagnosis

  • Lichen Planus
  • Psoriasis
  • Nummular eczema
  • Secondary syphilis
  • Seborrheic dermatitis

Most likely Diagnosis

Lichen planus is most likely because from the history the patient presented with a pruritic lesion on the left hand. On physical exam, the lesion is polygonal, purplish papules (Sullivan, 2019)

According to Kumar, Abbas & Aster (2017), a lichen planus lesion exhibits 5 P`s that is pruritic, papule, purplish, plaque and polygonal. The presence of small white papules in the mouth highly denotes lichen planus (Ball et all, 2019). Additionally, Lichen planus lesion has whitish visible lines known as Wickham striae that are pathognomonic of lichen planus (Kumar et al, 2017)

Diagnosis

Lichen planus in a patient with;

  • Hepatitis C
  • High blood pressure that is poorly controlled
  • Genetic predisposition to lichen plans
  • Works in a metal industry
  • Risk of chronic graft vs host reaction secondary to transplant due to chronic kidney failure
  • Chronic alcohol and cigarette smoking

Appendix: Skin condition graphic 1

References for JK with Itchy Skin Lesions Soap Note

Kumar, V., Abbas, A. and Aster, J., 2017. Robbins Basic Pathology E-Book. Saint Louis: Elsevier.

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

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.