Soap Note for Patient with Pimples on Left Arm

Patient Initials: _B.C. L______                      Age: 10 years_______                                    Gender: Male, African American_____

SUBJECTIVE DATA:

Chief Complaint (CC): “I have pimples on my left arm” (3)

Soap Note for Patient with Pimples on Left Arm

History of Present Illness (HPI): The patient was well until 3 days ago when he noticed small pimples on his left arm. They were of sudden onset, started as one pimple but progressed to several pimples consequently resulting in the notification of the mother. The pimples are itchy with no associated discharge or pain. The development of pimples is aggravated by scratching with no known relieving factors. There is no history of trauma to the area or contact with chemicals. However, the child reports his friend at school had similar pimples 2 months before.

Medications: Currently not taking any medications.

Allergies: No known food and drug allergies

Past Medical History (PMH): He has previously been admitted for 3 days secondary to pneumonia. Denies history of diabetes or hypertension. The HIV status is negative.

Past Surgical History (PSH): Denies past surgical treatment and blood transfusion.

Sexual/Reproductive History: Denies sexual abuse. No sexual debut.

Personal/Social History: Last born in a family of two. He is in the fourth year of study at the elementary school. He denies smoking tobacco or taking alcohol

Health Maintenance: Visits the local health facility annually for medical checkups. Adheres to a balanced diet.

Immunization History: Mother states that all immunizations are current. He has recently received the annual influenza vaccine

Significant Family History: No history of eczema or atopic dermatitis in the family. No history of contagious infections or similar symptoms in other family members. Soap Note for Patient with Pimples on Left Arm

Review of Systems:

General: He reports no hotness of the body, chills, nausea or vomiting, no generalized body malaise and no dizziness.

            HEENT: He reports no headache, blurring of vision, double vision, yellow sclera, ear pain, neck pain, hearing loss, ringing in the ears, sneezing, runny nose, or hoarseness.

            Respiratory:  He denies chest pain, sputum production, difficulty in breathing, cough, or chest tightness.

            Cardiovascular/Peripheral Vascular: He denies cough, breathlessness, awareness of heartbeat, and fatigue.

            Gastrointestinal: He reports no diarrhea, loss of appetite, abdominal pain, and dysphagia.

            Genitourinary: He reports no blood in urine, dysuria, frequent urination, and incontinence.

            Musculoskeletal: Denies back pains, muscle pains, joint pains, and change in mobility.

            Neurological: Denies loss of sensation, confusion, and cognitive changes.

            Psychiatric: He reports anxiety. No delirium, depression, or cognitive dysfunction.

            Skin/hair/nails: Mother reports no history of eczema/atopic dermatitis, hair loss, or nail loss.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 124/84 mmHg, temperature 98 F, HR 80bpm, RR 18 breaths/ min, SPO2 98%

General: Child, in a fair general condition, well-hydrated, of good nutrition status, and not in any form of respiratory distress. No conjunctival or palmar pallor, no jaundice, no central cyanosis, no peripheral limb edema, and no cervical or inguinal lymphadenopathy.

HEENT: Normocephalic head with normal hair distribution and texture. No eye, nasal, or ear discharge. No oral thrush and good oral health.

Neck: Soft neck, no masses or lymphadenopathy.

Chest/Lungs: Symmetrical chest moving with respiration, no obvious scars on inspection, trachea centrally located with no obvious masses on palpation, resonant chest on percussion. Vesicular breath sounds and no added sounds on auscultation.

Heart/Peripheral Vascular: Normal precordium, S1 S2 heard, no murmur, apex beat in the 5th intercostal space midclavicular, no heaves, and no thrills.

Abdomen: Non-distended abdomen, moves with respiration, no scars or lesions on inspection, no tenderness and organomegaly on palpation. Tympanic on percussion. Bowel sounds present on auscultation.

Genital/Rectal: no anal fissures or tags, no penile lesions or discharge.

Musculoskeletal: Normal muscle tone, normal bulk, power grade 5, and normal reflexes

Neurological: GCS 15/15, oriented to place, person, and time, memory is intact, intact sensory and motor function.

Skin: Slightly tender, multiple, rounded, dome-shaped, pink waxy papules approximately 5 mm that are umbilicated and contain a dimple at the center made of a caseous plug on the left arm. Skin in the other areas of the body normal.

Diagnostic results: Squash preparation revealed the Henderson-Paterson bodies. Histopathology demonstrated the classic cup-shaped invagination of the epidermis into the dermis with Henderson-Paterson bodies.

ASSESSMENT: The patient came to the clinic complaining of itchy, non-painful, contagious, non-discharging bumps on the left arm two months following a similar presentation by his friend. On examination, he is slightly worried although his pathology is localized at the left arm.

Main Diagnosis

The likely diagnosis is Molluscum contagiosum. This highly contagious infection presents about 6 weeks after contact (Forbat et al., 2017) and it is more common in school-going children and children who attend daycare and recreational facilities due to crowding or sharing of bath towels and other pieces of equipment. B.C.L presents two months after contact with his friend at the elementary school. In addition, the classic physical findings of tender, multiple, rounded, dome-shaped, pink waxy papules approximately 5 mm that are umbilicated with a caseous plug (Badri & Gandhi, 2021) points towards Molluscum contagiosum. Despite most individuals with molluscum being asymptomatic, the symptomatic cases mostly report pruritic lesions. The patient further does not experience systemic symptoms such as fever, nausea, or malaise (Leung et al., 2017). The symptomatology above is consistent with the one presented by B.L.C. Furthermore, the squash preparation showing Henderson-Paterson bodies and histopathology results demonstrating cup-shaped invagination of the epidermis into the dermis with Henderson-Paterson bodies are unique to molluscum contagiosum (Meza-Romero et al., 2019). However, other conditions can also present similarly and therefore must be ruled out.

Differential Diagnosis

Syringoma, a benign growth due to overactive sweat glands can be considered one of the differentials in children with molluscum (Badri & Gandhi, 2021) although this condition mostly develops in the neck, upper regions of the eyes, and upper cheeks as opposed to the arm region. Besides, the lesions associated with syringomas are rarely pruritic.

Warts can also manifest with such small, fleshy bumps on the skin or mucous membrane (Leung et al., 2017). Nevertheless, their microscopic findings are characteristic and show hyperkeratosis, papillomatosis, and acanthosis (Leung et al., 2017), as opposed to the Henderson-Paterson bodies seen in the histopathology results of B.C.L. Lastly, Badri and Gandhi (2021), recommends ruling out cutaneous manifestations of opportunistic infections such as cryptococcosis, histoplasmosis, and aspergillosis which mimic Molluscum contagiosum. Noteworthy is that these conditions are common in an immunocompromised host, which is not the case with B.C.L. who is HIV negative and reports no history of diabetes mellitus.

Cryptococcosis can be cultured as opposed to Molluscum contagiosum and its histologic findings reveal an oval, thick-walled spherule surrounded by a thick polysaccharide capsule which is usually revealed by special staining such as methylene blue. Other lesions which can present similarly but beyond the exploration in this particular paper are closed comedones, herpes simplex, chickenpox, and folliculitis.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

Soap Note for Patient with Pimples on Left Arm References