NSG6435 Week 3 SOAP Hughes S

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South University, Savannah *

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6435

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Biology

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Jan 9, 2024

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1 CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Student Name: Stephanie Hughes Course: NSG6435 Patient Name: T.G. Date: 10/2/1983 Time: 10:16 am Ethnicity: African American Age: 14 Sex : Male SUBJECTIVE (must complete this section) CC : The mother verbalized, “My son has had this rash and I thought it was getting better, but it’s coming back. I would like to have it looked at.” HPI : The patient presents with a rash located on the upper and lower body. The color is described as pink. The onset of symptoms x3 weeks. The mother states she purchased oatmeal bodywash to see if that would help. However, it has not been of any help. Medications : NONE Previous Medical History: None Developmental History: T.G. is an overall well developed and was a full-term baby. T.G. is doing well in school, he can make choices for himself such as his friendships. He is starting puberty as his voice cracks between words. He spends time on the weekends hanging out with his friends. T.G. is also showing interest in finding work around the home to make extra money to have on the weekends. Allergies: NKA Medication Intolerances: NKDA Chronic Illnesses/Major traumas: None Immunizations: Up to date on all immunization/last flu vaccine 10/2022 Hospitalizations/Surgeries: None Health Promotion/Health Maintenance: T.G. should have a caloric intake of 2,800 per day. He should choice foods high in protein and decreased sugary drink intake Nutrition/Diet: Regular diet Exercise/Regimen: Runs 2-3 times per week for 30 mins at a time Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: The patient is not exposed to any of the following in question. The patient denies the use of any of the following in question Safety Measures: The patient was educated on the importance of seatbelt safety while riding in a motor vehicle. He was educated on the dangers of engaging in illicit drug use and sexual behavior. T.G. was also educated on the importance of keeping in touch with his parents when he is not at home. Screening exams: During T.G.’s yearly wellness exam this year the patient had his height and weight checked along with his BMI. Vision and hearing were normal. He was also sent to the lab for screen of hypercholesterinemia, and anemia. He had a normal cervical check. He also received his meningococcal, HPV and TDAP. He is due for his annual flu vaccine. F AMILY HISTORY (must complete this section) M : No significant medical history MGM: No significant medical history MGF : HTN and DMII F : HTN PGM: HTN PGF: HTN and CAD Social History: The patient lives at home with his mother and 3 siblings. He has a pet dog and pig. He has a relationship with his father, and both sets of grandparents. The patient and his siblings get along well.

2 The patient is active in school, making good grades, and works around the home doing chores for extra money of his own. REVIEW OF SYSTEMS (must complete this section) General : C/O rash on the upper and lower body with the onset x3 weeks. Cardiovascular : Denies chest pain or palpitations Skin : C/O pink rash on the upper and lower part of his body. Denies any other lesions or open areas of concern. C/O of the rash itching at times. Respiratory: Denies feeling SOB or cough Eyes : Denies any visual changes. Denies requiring glasses or contact lenses. Gastrointestinal: Denies any abdominal pain, nausea, or vomiting Ears : Denies any hearing complications Genitourinary/Gynecological: Denies any problems with voiding, penile, or scrotal discomfort Nose/Mouth/Throat: Denies any complications with his sinuses, dysphagia, or sore throat Musculoskeletal: Denies any joint or muscle pain Breast: Denis any changes in breast Neurological : denies any headaches, neck pain, weakness, or syncope Heme/Lymph/Endo: Denies any complications with diet and denies any malaise Psychiatric : Denies any anger or thoughts of suicidal ideation OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight : 105 Height : 5’5” BMI : 17.5 BP: 98/68 Temp : 97.7 F oral Pulse: 61 Resp : 14 SPO2 %: 98 RA General Appearance: Overall: well, developed, in no acute distress and well nourished Skin : Presents with dryness, flesh-colored lesions to the trunk, back and abdomen. It presents as macule/patch and central clearing. Herald patch noted around some of the lesions on the trunk. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. Bilateral eye erythema, bilateral eyelids present with erythema, and bilateral conjunctiva erythematous with drainage noted. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized bilateral myringotomy tubes. Nose: Nasal internal turbinate’s erythema. Bilateral thick purulent drainage. No septal deviation. Neck: Supple. Full ROM; The cervical anterior lymph nodes are non-tender and bilaterally upon palpation; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Tonsilopharyngeal area non-erythematous. Oropharyngeal no drainage noted. Teeth are in good repair. Cardiovascular: No gallops, no rubs, regular rate, normal heart sounds no murmurs. Respiratory : Respirations even and unlabored. Lungs clear to auscultation anterior and posterior bilaterally. Gastrointestinal: Defer Breast : Defer Genitourinary : Defer Musculoskeletal: Defer Neurological: Defer

3 Psychiatric : Defer Diagnostic Studies : None Special Tests: None currently 06062023 Page 1 of 2 C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s DIAGNOSIS (must complete this section) Differential Diagnoses • Tinea Corporis B35.4 ( Adams, 2002) • Atopic Dermatitis L20.9 (Eichenfield et al., 2014) • Guttate Psoriasis L40.4 (Ferrándiz et al., 2002) Diagnosis • Pityriasis rosea-like skin eruption: L42 (Drago et al., 2019) Plan/Therapeutics: Medication:  Diflucan 150 mg tablet take 1 tablet po QW for 21 days start on Oct. 2, 2023, and end on October 22, 2023  Selenium Sulfide 2.5% lotion apply 1 application topical QD apply to the affected area, leave on 10 minutes, rinse, x7 days starting Oct 2, 2023, stopping on Oct 8, 2023 Non-Medication Treatment:  Take an oatmeal bath. Use lukewarm water, not hot water.  Use unscented moisturizing lotion or cream on your skin.  Try to keep your body cool .  Do not scratch the areas if they itch Diagnostics: None Education Provided: The patient is known to be non-complaint with his medication treatment. The patient and mother were educated on making sure that he completes all his medication. However, if his symptoms do not resolve after this treatment then we will make a referral for his to receive phototherapy. The mother was educated as though the patient is old enough to take his own medication, but it is her responsibility to make sure the patient is following through with his medication treatment. The patient and the mother were advised that the rash may persist for two to three months; no follow-up is necessary as long as it resolves within this time. New lesions may occur during this period but should disappear spontaneously. Relapse after resolution is uncommon (Drago et al., 2009). The cause is unknown, but it does not seem to spread from person to person easily. Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect: Signs of an allergic reaction, like rash ; hives; itching ; red, swollen, blistered, or peeling skin with or without fever; wheezing ; tightness in the chest or throat; trouble breathing, swallowing, or

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4 talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. Redness. Irritation where selenium sulfide lotion is used ( Selenium Sulfide Lotion: Indications, Side Effects, Warnings - Drugs.com , 2023). Make sure to complete the full three-day course of Diflucan Sodium as it is used to treat fungal infections. I would also recommend washing all bed linens in hot water, towels, and previous worn clothing. Do not share towels, clothing, or bed linen until the rash has cleared up. The mother was educated that if the patient’s condition changes, becomes worse, or he has a severe reaction to the medication prescribed and report to the ED. The Mother was also instructed that we would like to see the patient back in the office in 2-3 weeks or prn to see how effective the treatment regimen is working for the patient. The mother verbalized understanding. 06062023 Page 2 of 2 Week 3 SOAP NOTE Stephanie Hughes South University NSG 6435 Dr. Loewen October 9, 2023

5 Abstract The patient presents with a rash located on the upper and lower body. The color is described as pink. The onset of symptoms x3 weeks. The mother states she purchased oatmeal bodywash to see if that would help. However, it has not been of any help.

6 Week 3 SOAP NOTE Primary Diagnosis L42 Pityriasis rosea-like skin eruption: Pityriasis rosea is a benign, self-limited disorder. Pityriasis rosea is an acute, self-limited, exanthematous skin disease characterized by the appearance of slightly inflammatory, oval, papulosquamous lesions on the trunk and proximal areas of the extremities. In most cases the papules and plaques resolve in four to six weeks; occasionally the disease will persist for several months. Postinflammatory hyperpigmentation is a common sequela in individuals with darkly pigmented skin and often takes several months or longer to resolve. In 50 to 90 percent of cases, the eruption begins with a "herald" or "mother" patch, a single round or oval, sharply delimited lesion on the chest, neck, or back The herald patch is usually 2 to 5 cm in diameter. The lesion soon becomes scaly and begins to clear centrally, leaving the free edge of the cigarette paper-like scale directed inwards toward the center. This clinical finding is often described as a "collarette" of scale (Drago et al., 2019). The lesions themselves also are sometimes atypical in children; they may be folliculo- papular, vesicular, pustular, urticarial, or purpuric. PR generally has only mild effects on quality of life in children (Chuh, 2003). Treatment do not take selenium sulfide lotion by mouth. Use on your scalp and hair only. Keep out of your mouth, nose, ears, and eyes (may burn). Wash your hands before and after use. To use as a shampoo, wet hair and scalp. Lather well and leave on as you have been told. Rinse fully. Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect: Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever;

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7 wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. Irritation where selenium sulfide lotion is used ( Selenium Sulfide Lotion: Indications, Side Effects, Warnings - Drugs.com , 2023). For mild, uncomplicated, infections fluconazole is prescribed as a single 150 mg dose and an improvement in symptoms is usually seen within one to three days. If a single dose does not completely relieve symptoms, or the infection is severe, fluconazole can be prescribed as three consecutive doses given three days apart. With this regimen it's expected that symptoms should improve within one to two weeks ( Fluconazole - How Long Does It Take to Work? , 2023). Differential Diagnosis: B53.4 Tinea Corporis: Tinea corporis often begins as a pruritic, circular or oval, erythematous or hyperpigmented, scaling patch or plaque that spreads centrifugally. Central clearing follows, while an active, advancing, raised border remains. The result is an annular (ring-shaped) plaque from which the disease derives its common name ring worm (Adams, 2002). This can be confused at times with Pityriasis rosea as they both present with herald patches. However, this was ruled out as a diagnosis as the patient denies having any close contact with anyone who is being treated with Tinea Corporis. The mother also denies anyone else in the home having this condition. L20.9 Atopic Dermatitis: Atopic dermatitis is a chronic, pruritic, inflammatory skin disease that occurs most frequently in children but also affects adults. Atopic dermatitis is often associated with an elevated serum level of immunoglobulin E (IgE) and a personal or family history of atopy, which describes a group of disorders that includes eczema, asthma, and allergic

8 rhinitis (Eichenfield et al., 2014). Although sensitization to environmental or food allergens is clearly associated with the atopic dermatitis phenotype, it does not seem to be a causative factor but may be a contributory factor in a subgroup of patients with severe disease (Williams & Flohr, 2006). I was able to rule this out as the patient has no history of environmental or food allergies;nor does he have a family history. Also, this does not present with a herald patch as the patients skin does not present with hareld patches. L40.4 Guttate Psoriasis: Psoriasis is a common skin disorder characterized by the development of inflammatory plaques on the skin. The spectrum of clinical manifestations of psoriasis is wide and includes chronic plaque, guttate, inverse, erythrodermic, pustular, and nail variants of the disease. Patients with guttate psoriasis typically present with the acute onset of numerous small, inflammatory, scaly plaques on the trunk and extremities. Guttate psoriasis is most common among children and young adults, and a preceding history of streptococcal infection is often present (Ferrándiz et al., 2002). I was able to rule this out as a diagnosis due to the fact that the patient has not recently had a streptococcal infection, varicella, or a tattoo. All of these are related to the cause of Guttate Psoriasis. Guttate psoriasis is characterized by the acute eruption of numerous small, erythematous papules and plaques. The term "guttate" is utilized to refer to the discrete, drop-like appearance of skin lesions. The eruption may present as a new- onset disorder in patients without a history of psoriasis or as a new presentation of psoriasis in patients with pre-existing chronic plaque-type disease. Individual lesions usually measure between 2 and 15 mm in diameter and demonstrate fine, overlying scaling. The trunk and proximal extremities are classically involved, although lesions may also occur in other sites, such as the scalp, hands, feet, and nails (Ko et al., 2010). Though the patent did present with scaly

9 patches in the areas listed above. The one thing different the patient presented with were herald patches and that is also another reason I ruled this out as a primary diagnosis.

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10 References Adams, B. B. (2002). Tinea corporis gladiatorum. Journal of the American Academy of Dermatology , 47 (2), 286–290. Retrieved October 5, 2023, from https://doi.org/10.1067/mjd.2002.120603 Chuh, A. T. (2003). Quality of life in children with pityriasis rosea: A prospective case control study. Pediatric Dermatology , 20 (6), 474–478. Retrieved October 5, 2023, from https://doi.org/10.1111/j.1525-1470.2003.20603.x Drago, F., Broccolo, F., & Rebora, A. (2009). Pityriasis rosea: An update with a critical appraisal of its possible herpesviral etiology. Journal of the American Academy of Dermatology , 61 (2), 303–318. Retrieved October 5, 2023, from https://doi.org/10.1016/j.jaad.2008.07.045 Drago, F., Ciccarese, G., & Parodi, A. (2019). Is there a relationship between environmental factors and pityriasis rosea? reply to singh et al. Acta Dermatovenerologica Alpina Pannonica et Adriatica , 28 (4). Retrieved October 5, 2023, from https://doi.org/10.15570/actaapa.2019.45 Eichenfield, L. F., Tom, W. L., Chamlin, S. L., Feldman, S. R., Hanifin, J. M., Simpson, E. L., Berger, T. G., Bergman, J. N., Cohen, D. E., Cooper, K. D., Cordoro, K. M., Davis, D. M., Krol, A., Margolis, D. J., Paller, A. S., Schwarzenberger, K., Silverman, R. A., Williams, H. C., Elmets, C. A.,...Sidbury, R. (2014). Guidelines of care for the management of atopic dermatitis. Journal of the American Academy of Dermatology , 70 (2), 338–351. Retrieved October 5, 2023, from https://doi.org/10.1016/j.jaad.2013.10.010

11 Farber, E. M., & Nall, L. (1974). The natural history of psoriasis in 5,600 patients. Dermatology , 148 (1), 1–18. Retrieved October 4, 2023, from https://doi.org/10.1159/000251595 Ferrándiz, C., Pujol, R. M., García-Patos, V., Bordas, X., & Smandía, J. A. (2002). Psoriasis of early and late onset: A clinical and epidemiologic study from spain. Journal of the American Academy of Dermatology , 46 (6), 867–873. Retrieved October 5, 2023, from https://doi.org/10.1067/mjd.2002.120470 Fluconazole - how long does it take to work? (2023, September 11). Drugs.com. Retrieved October 5, 2023, from https://www.drugs.com/medical-answers/fluconazole-long-work- 1947155/ Ko, H.-C., Jwa, S.-W., Song, M., Kim, M.-B., & Kwon, K.-S. (2010). Clinical course of guttate psoriasis: Long-term follow-up study. The Journal of Dermatology , 37 (10), 894–899. Retrieved October 5, 2023, from https://doi.org/10.1111/j.1346-8138.2010.00871.x Selenium sulfide lotion: Indications, side effects, warnings - drugs.com . (2023, August 1). Drugs.com. Retrieved October 5, 2023, from https://www.drugs.com/cdi/selenium- sulfide-lotion.html Williams, H., & Flohr, C. (2006). How epidemiology has challenged 3 prevailing concepts about atopic dermatitis. Journal of Allergy and Clinical Immunology , 118 (1), 209–213. Retrieved October 5, 2023, from https://doi.org/10.1016/j.jaci.2006.04.043