Skin Condition IMAGE 5 Differential Diagnosis for Skin Conditions NURS 6512: ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING December 22, 2018 SOAP CHARTING Chief Complaint: “I have red itchy patches over my knees and elbows.”
Skin Condition IMAGE 5 SUBJECTIVE : A 21-year-old Latino female arrives at the clinic with c/o multiple small red spots to her face, elbows, and knees. The client reported the itching and “getting worse” for nearly three weeks. She has tried multiple lotions and creams, including hydrocortisone cream for the rash, without relief. The client has a pending dermatology appointment, but the earliest appointment in May. The client is attending cosmetology academy at Vista College, visiting her fiancé, soon and planning her graduation in June as well. The client states “I ‘can’t wait till May, I have a lot of planning, for my graduation and vacation.” I look horrible; my skin is scaly, I look like a snake”. I’ve been under so much stress with school and planning my vacation and graduation”. “Can you help me right now. MEDICATIONS: None, Albuterol “when I was a kid.” Past Medical History: Pneumonia age 2 Past Surgical History: None Family History: Great Aunt diagnosis with Lupus in 30s, still living. Paternal Grandmother with Psoriasis and Paternal Uncle with Psoriasis Mother 48 living no history Father 46 Living no history Sister 16 Brother 12 Brother 10 OBJECTIVE : alert and oriented x3, anxious mood and standard body structure for her age and race. The patient’s frontal scalp, face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally were examined, and there were 2-4 mm pink, rough, keratotic macules on the right and left jaw area, and on in the inside of the elbows bilaterally. The rash is 2
Skin Condition IMAGE 5 localized to bilateral knees. They were 1 to 2.5 cm, pink, very slightly scaly plaques. Note: There is mild erythema with slight scale on the palmar surface of both hands, not reported by the client.
- Spring '19
- Systemic lupus erythematosus, Cutaneous conditions, plaque psoriasis