Comprehensive SOAP Template
Patient Initials: ZY Age: 65 Gender: Female
SUBJECTIVE DATA:
“I have multiple red raised lesions all over my chest and stomach”. This happened about two weeks ago
Chief Complaint (CC): Multiple raised red spots all over torso (image #2).
History of Present Illness (HPI): A 65-year-old Caucasian male presents to the clinic with multiple red papule all over torso. The spots are red in color, some raised and some are flat to the skin. There are about 48 spots and they look like little cherries and have rough and smooth edges to it. It started about two weeks ago with 5 spots and gradually increased to about 48 spots. There are no relieving or aggravating factors.
You must include the 7 attributes of each principal symptom:
Location
Quality
Quantity or severity
Timing, including onset, duration, and frequency
Setting in which it occurs
Factors that have aggravated or relieved the symptom
Associated manifestations
Medications: None
Allergies: NKA
Past Medical History (PMH): None
Past Surgical History (PSH): None
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Use alcohol occasionally. Sedentary lifestyle
Immunization History: pneumonia vaccine 10/2019
Significant Family History: mother has a hx of diabetes and father has a hx of hypertension
Lifestyle: Retired and receiving unemployment checks
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Red raised and slightly elevated lesion with distinct edges, about 48 lesions on torso.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin: Multiple red raised skin lesions scattered all over torso approximately 48 lesions, round in shape and some flat to the skin with distinct edges in varying sizes are about 0.5-1mm. no exudates or bleeding noted.
ASSESSMENT: Diagnostic testing is not needed for this patient
Diagnosis: Cherry Angiomas
Differential Diagnosis: Angiokeratoma, Pyogenic granuloma and Nodular basal cell carcinoma
A cherry angioma is a small papular angioma. It is also called a senile angioma. (Oakley, 2017). They occur in virtually everyone older than 30 years and increase numerically with age (Ball et al., 2018). Cherry angiomas are not usually painful and spread everywhere on the body. “In their early, and smaller, stages they are typically maraschino cherry red, hence the name cherry angiomas. As they enlarge or become thrombosed, some lesions become darker red or even black in color” (MDedge Family Medicine, 2019). “Cherry angiomas do not require treatment. If treatment is desired for cosmetic purposes, they can be treated with electrocautery, cryosurgery, or laser” (MDedge Family Medicine, 2019).
“Angiokeratoma is a benign skin lesion, appearing more commonly in older individuals. Angiokeratomas can be described as wart-like, red to black papules. Angiokeratomas vary in color, size, and shape; however, they are usually dark red to black in color. They range in size from papule lesions (up to 5 millimeters in size) to small plaque lesions (6 millimeters or higher in size). When touched, angiokeratomas feel hard and cannot be blanched, or faded, by compressing them. They may have an uneven surface described as “pebbled” (aocd.org, n.d.).
It is most definitely not a pyogenic granuloma because “Pyogenic granuloma is a relatively common skin growth. It is usually a small red, oozing and bleeding bump that looks like raw hamburger meat. It often seems to follows a minor injury and grows rapidly over a period of a few weeks to an average size of a half an inch.” (aocd.org, n.d.).
“Nodular basal cell carcinoma comprises about 60-80% of the cases and occurs most often on the skin of the head. Clinically it is presented by elevated, exophytic pearl-shaped nodules with telangiectasie on the surface and periphery” (Dourmishev, Rusinova, & Botev, 2013). Knowing this, it is very obvious this is not the diagnosis for this patient. “The lesions with big sizes and the central necrosis are defined as ulcus rodens” (Dourmishev et al., 2013).
List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses
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