1 Differential Diagnosis Alvin L. Johnson NURS 6512 Advanced Health Assessment Walden University Week 4Assignment
2 Differential Diagnosis SOAP NOTE Differential Diagnosis for Skin Condition Skin Condition Picture #4 Patient Initials: RJ Age: 33 Gender: F SUBJECTIVE DATA: Chief Complaint (CC): Complains of pain under right armpit with a type of skin growth. History of Present Illness (HPI): Renee’ Johnson is a 33-year old African-American female who presents today with a chronic complaint of pain to right axilla. She reports to the pain beginning approximately four weeks prior to the visit and noticed the pain while bathing underneath the right axillary. Upon completion of her bath, she observed a small growth in this same area. She reports doing a self-examination and noticing a “skin growth” to the upper part of the area with no hemorrhaging but slight redness when it has been irritated. She reports the need to keep the axilla areas shaved due to the hair surrounding the skin growth wrapping around it at times an pulling it. There are also times when it gets caught on her clothing and is pulled and causes pain. She does not complaint of any itching to the site or surrounding area. She has attempted to remove the skin growth by tying dental floss to the top of it without success. She reports the severity of pain at the moment to be 3/10. Medications: 1) Neurontin 300 mg TID 2) Zoloft 25 mg orally daily.
3 Differential Diagnosis 3) Hydrocodone/Acetaminophen 7.5/325 mg Q4H PRN Allergies: No Know Drug Allergies Past Medical History (PMH): Fibromyalgia diagnosis three years ago. Treatment occurs daily outside of admission to a medical treatment facility. Prescribed medications to treat the condition.
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- Summer '15