NURS 6512 Week 4 Differential Diagnosis for Skin Condition Example

SOAP NOTE

Differential Diagnosis for Skin Condition

Patient Initials: BA                                        Age: 84                                                                        Gender: F

SUBJECTIVE DATA: Left axillary skin tag/growth pain. Chief Complaint (CC): Skin Condition Picture #4 History of Present Illness (HPI):

Mrs. Barbara Acosta is an 84-year old Caucasian female with COPD, A-Fib, non- melanoma skin cancers, and CHF with a left-sided pacemaker who came in today concerned about this new painful axilla growth. The patient stated approximately four weeks ago, she was in the shower and palpated a skin growth mass in her left axilla, and it was tender and hurting her.

NURS 6512 Week 4 Differential Diagnosis for Skin Condition Example

She reports no bleeding, but when it gets irritated, it becomes red and swollen. She stated she has been shaving the area due to the hair growth irritates the growth more. The growth also gets caught on her clothing and pulls it and causes pain. Denies any itching or dryness to the site or immediate area. The current pain level is 4/10, but states with her history of skin cancers, and she is highly anxious. NURS 6512 Week 4 Differential Diagnosis for Skin Condition Example

Medications:

  • Metoprolol Tartrate 100mg oral, 1 tab, PO, Daily
  • Isosorbide Mononitrate 30mg oral, extended-release, 1 tab, PO, QAM
  • Furosemide 20mg oral, 1 tab, PO, Daily
  • Montelukast 10mg oral, 1 tab, PO, QPM
  • Atorvastatin 20mg oral, 1 tab, PO, Daily
  • Famotidine 20mg oral, 1 tab, PO, Daily
  • Albuterol 90 mcg/inh, 1 puff, QID, PRN: for Wheezing
  • Eliquis 5mg oral, 1 tab, PO, BID

Allergies: No Know Drug Allergies, No known food allergies, No known latex allergies

Past Medical History (PMH): Of note patient has a pacemaker on the left side that is very close to the skin growth, and she has the pacemaker for a history of atrial fibrillation and CHF. The patient also has a history of chronic bronchitis and asthma. History of non-melanoma skin cancers.

Past Surgical History (PSH): Tonsillectomy 1941, Appendectomy 1947, Hysterectomy 1980, CABG 199, Pacemaker 2015.

Sexual/Reproductive History:

Heterosexual, Gravida 3, Para 3, Abortus 0, Postmenopausal, Age at menopause 45.

Personal/Social History: Quit smoking 1990. Smoked 20 years. Denies alcohol or substance use. Moderate sun exposure, she does use sunscreen.

Immunization History: Immunizations are up to date. Tdap was in 2012. Influenza vaccine November 2019. Pneumococcal vaccine received in 2016.

Significant Family History:

Mother-deceased at age 78 from breast cancer. Father-deceased at age 77 from hypertension.

Maternal grandfather- deceased at age 66, died from heart disease. Maternal grandmother- deceased at age 66, died from a stroke

Paternal grandfather- deceased at age 81, died from colon cancer. Paternal grandmother-deceased at age 78, died from a heart attack. Son- Living, No health issues, age 60

Daughter- Living, Asthma, age 58 Daughter- Living, hypertension, age 61

Sister- Living, Asthma, Heart Disease, age 86

Lifestyle: Mrs. Acosta has a technical trade school education; she is currently retired, formally employed as an administrative assistant (hospitality industry). She is presently married and lives with her husband. She has support at home from her husband, and her children live close by and are a good support system for Mrs. Acosta. She regularly goes to church and has a close church family as support as well.

Review of Systems:

General: Alert and oriented, no acute distress.

HEENT: Oropharynx clear, Oral mucosa is moist, No pharyngeal erythema.

Neck: Supple, Non-tender

Breast: Left axillary growth measuring 2cm X 2 cm. No palpable right or left breast mass.

Respiratory: Respirations are non-labored. Lungs are clear to auscultation. Breath sounds are equal.

CV: Normal rate, Regular rhythm, No murmur.

GI: Soft, non-tender, non-distended, positive bowel sounds GU: Denies urgency, frequency, nocturia, and incontinence. MS: Denies back or joint pain, has a full range of motion. PSYCH: Cooperative, appropriate mood, and affect.

NEURO: Alert and oriented X4

INTEGUMENT/HEME/LYMPH: Warm, dry, no rash, left axilla skin growth ENDOCRINE: No abnormalities, not on hormone replacement ALLERGIC/IMMUNOLOGIC: No known allergies, no recurrent fevers OBJECTIVE DATA-

PHYSICAL EXAM:

B/P: 141/82, left arm P: 69 BPM regular rate T: 97.7 DegF Oral

RR: 16 br/min- non labored

Sp02: 98% -Room air

Wt: 63.7 Kg

BMI: 26.86

Ht: 60.6 inches- standing height

General: Mrs. Acosta is in good health but does have some comorbidities. She is alert and oriented X4; her husband is with her and provides excellent support. She is dressed appropriately, follows instructions, and askes the right questions. Full activity level.

HEENT: Oropharynx clear, Normocephalic, Normal hearing, Oral mucosa moist.

Neck: Supple, Non-tender, No lymphadenopathy

Chest/Lungs: Lungs are clear to auscultation, Respirations are non-labored, breath sounds are equal, Symmetric chest wall expansion, No chest wall tenderness.

Heart/Peripheral Vascular: Normal rate, Regular rhythm, No murmur, No edema Abdomen: Soft, non-tender, Nondistended, normal bowel sounds, no organomegaly Musculoskeletal: Normal range of motion, Normal strength, No tenderness, No swelling Neurological: Alert, Orientated, No focal defects

Skin: Warm, Dry, Intact, No edema, No rash, Visual skin growth left axilla

ASSESSMENT:

DIFFERENTIAL DX:

  • Cutaneous Tag/Skin Tag (Acrochordon)
  • Squamous cell carcinoma of left axilla (history of multiple SCC)
  • Seborrheic Keratoses
  • Common warts

DIAGNOSIS/CLIENT PROBLEM:

Cutaneous tag/ skin tag (Acrochordon) are papillomas commonly found in the neck and axillae region of the middle-aged and elderly population (Ball et al., 2019). Acrochordon is the most likely diagnosis for Mrs. Acosta. Due to Mrs. Acosta’s history of non-melanoma skin cancers, we don’t want to rule out a Squamous cell carcinoma. Early detection of squamous cell carcinoma of the skin can be easily treated (Goh, Howle, Hughes, & Veness, 2009). It is essential to report any new changes or unusual skin growths (Goh et al., 2009). Mrs. Acosta’s skin growth is skin-colored, small 2cm, and fleshy. Skin tags are not traditionally painful but can be tender or irritated by touched or caught on clothing (Colyar, 2015). Skin tags tend to grow in skin folds but can appear anywhere on the body (Hay et al., 2011).

References

  • 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. https://www.elsevier.com/books/seidels-guide-to-physical-examination/ball/978-0-323-48195-3
  • Colyar, M. R. (2015). Advanced practice nursing procedures.
  • Goh, A., Howle, J., Hughes, M., & Veness, M. J. (2009). Managing patients with cutaneous squamous cell carcinoma metastatic to the axilla or groin lymph nodes. Australasian Journal of Dermatology, 51(2), 113-117. doi:10.1111/j.1440-0960.2009.00576.x
  • Hay, R. A., Kadry, D., Zeid, O. A., Safoury, O. E., Fawzy, M., Amin, I., & Rashed, L. (2011). Skin tags, leptin, metabolic syndrome, and change of the lifestyle. Indian Journal of Dermatology, Venereology, and Leprology, 77(5), 577. doi:10.4103/0378-6323.84061