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 Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week's Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

 Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature.

Comprehensive SOAP

Patient Initials: __JJ_____ Age: __54_____ Gender: __M_____

SUBJECTIVE DATA:

Chief Complaint (CC): Small, itchy, raised patches on lower back

History of Present Illness (HPI): Jeremiah Jergens is a 54-year-old Caucasian male who presents today with a large cluster of thick, red, raised patches on his lower back. Jeremiah first noticed the patches 4 years ago, a few days after he recovered from a strep throat infection. He has associated symptoms of tenderness, itchiness and flaking of the patches. They often bleed when he accidently scratches off a patch. He reported the he is “embarrassed by the look of it” and will not take his shirt off at the beach. He has also noticed both his knees, joints in his fingers and back are very stiff in the mornings but lessens after walking and using his joints for a bit. He has been using Tylenol to help withthe joint pain and for the patches, he reports using Benadryl ointment for the itching. Both provide minimal relief. He rates his discomfort a 4/10 today but in mornings 7/10 due to the joint pain.

Medications: 1. Over-the-counter Tylenol 500mg PO once daily in the morning

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2. Over-the-counter Benadryl Extra Strength topical ointment as needed3. Atenolol 75 mg PO twice daily4. Over-the-counter Aspirin 325 mg PO once daily5. Men’s Multivitamin once daily6. Epi-Pen as needed

Allergies: 1. Penicillin – rash2. Salmon – anaphylaxis3. Peaches – lip itching

Past Medical History (PMH): 1. Chicken Pox – age 52. Streptococcal Pharyngitis, recurrent– age 503. Morbid obesity

Past Surgical History (PSH): 1. Gastric bypass surgery – age 522. Appendectomy – age 233. Tonsillectomy – pt states “I was about 7 years old”4. Vasectomy – age 32

Sexual/Reproductive History: HeterosexualVasectomy – age 32

Personal/Social History: He quit smoking 8 months ago after smoking 2.5 packs daily x 31 years; has an occasional beer during social outings; denies any drug use; enjoys hiking, riding his motorcycle, spending time at the beach with his 5 grandchildren; exercise 5 days a week; eating habits have been “much better since the weight loss surgery”.

Immunization History: Agrees to receive his influenza and Pneumococcal today. All other immunizationsare up to date.

Significant Family History: Diabetes – mother dx late 30sHypertension – maternal grandparents, mother, brother all dx in late 30sArthritis – paternal grandfather, father both dx early 40sPsoriasis – father dx date unknown2 healthy daughters and 2 grandchildren

Lifestyle:

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He is married to his wife of 32 years. Together they travel the country in their RV and motorcycles. He has owned his home for the past 28 years in the suburbs. At 25 years as a U.S. Marine, he retired and receives full benefits of $75,000 annually. He and his wife both receive social security benefits. No financial issues. First born daughter rents the basement with her 2 children ages 5 and 12.

Following his gastric bypass surgery, his health taken a turn for the better by decreasing his meat and increasing his vegetable intake. His total weight loss since the surgery is 143 lbs. He is now only taking one blood pressure medication, down from two. 5 days a week, he exercises at the local YMCA. When he is not traveling the country, he attends church Mondays and Thursdays for Bible study. He also leads the marriage ministry for newlyweds. He has a great support system including his friends and family.

Review of Systems:

General: Negative for recent sudden weight changes, weakness, fatigue, anorexia, malaise, or fever

HEENT: negative for headache, head injury, visual changes, blurring of vision, itching, last eye exam 2/15/18. Negative for diplopia, floaters, loss of any visual fields, history of cataracts or glaucoma, pain, redness, excessive tearing. Negative for tinnitus, recent ear infections, hearing loss, change in hearing. Negative for epistaxis, frequent colds, nasal congestion, discharge, pain, post-nasal drip, change in ability to smell, history of nasal polyps, hay fever, and sinus trouble. Negative for mouth soreness, dryness, bleeding gums, throat soreness, pyorrhea, ulcers, and teeth dentures. Positive for recurrent strep throat infections (3 within 5 months) and dental caries.

Neck: negative for painful lymphnodes, enlarged lymphnodes, goiter

Breasts: negative for new or changing breast lumps, nipple changes or nipple discharge, gynecomastia

Respiratory: negative for cough, hemoptysis, wheezing, shortness of breath, dyspnea, pleuritic chest pain, cyanosis, recurrent pneumonia, environmental exposure, history of exposure to TB, last TB skin test 4/3/17-negative

Cardiovascular/Peripheral Vascular: negative for chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, edema, palpitations, murmur, varicosities, history of rheumatic fever, syncope, claudication, thrombophlebitis. Positive for hypertension and history of abnormal electrocardiogram

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Gastrointestinal: negative for abdominal pain, nausea, vomiting, hematemesis, constipation, diarrhea, hemorrhoids, dysphagia, odynophagia, food intolerance, early satiety, indigestion, heartburn, change in appetite, change in bowel pattern, rectal bleeding, melena, excessive flatulence or belching, liver or gallbladder problems, jaundice, history of hepatitis

Genitourinary: negative for dysuria, penile discharge, lesions, incontinence, changes in voiding, hematuria, frequency, suprapubic pain, nocturia, trouble initiating urinary stream, incomplete emptying, polyuria, stones, history of urinary tract infections, history of sexually transmitted infections, testicular pain, or swelling, scrotal mass, sexual difficulties, impotence, hernias. Positive for vasectomy at age 32

Musculoskeletal: negative for new gait disturbance, new weakness, recent fall, gout, arthritis. Positive for lower back pain, pain in joints of fingers, bilateral knee pain and stiffness with limited range of motion especially in the mornings

Psychiatric: negative for depression, anxiety, hallucinations, suicidal ideation, homicidal ideation, nightmares, nervousness, irritability, hypersomnia, insomnia, phobias. Positive for low self-esteem due to finger nail changes and patches on back

Neurological: negative for headaches, numbness/tingling, visual changes, seizures, falls, blackouts, local weakness, tremors, memory changes, muscle atrophy, vertigo or dizziness

Skin: negative for skin lesion changes, petechiae, bruising, sores, changed in moles, changes in hair.

Hematologic: negative for hematemesis, hematochezia, hemoptysis, prolonged bleeding, other bleeding problems, blood transfusion

Endocrine: negative for polyphagia, polyuria, polydipsia, heat intolerance, cold intolerance, sudden weight gain, sudden weight loss, history of diabetes or thyroid issues

Allergic/Immunologic: negative for seasonal allergies, recurrent serious infections. Positive for food allergy to salmon and peaches. Positive for drug allergy for Penicillin.

OBJECTIVE DATA:

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General: Alert and orientated to time, place, and person, well appearing, and in no distress. Appears comfortable during history taking

HEENT: Skull normocephalic, atraumatic, sparse hair with balding. PERRLA, light reflex present, oronasopharynx is clear

Neck: supple, no palpable thyroid, midline trachea, no enlarged neck nodes, bruit, jugular vein distension, tmegally

Chest/Lungs: clear to auscultation, no wheezes, rales or rhonchi, rubs, symmetric air entry, resonance on percussion, fremitus on palpation

Heart: normal rate, regular rhythm, normal S1, S2, no murmurs, thrills, rubs, clicks or gallops

Peripheral Vascular: peripheral pulses normal, no pedal edema, no clubbing or cyanosis

Abdomen: Abdomen soft, nontender, nondistended, no scars, masses hernia, aortic pulsations, or organomegaly, bowel sounds present

Genital/Rectal: No penile lesions or discharge, testicular lump, no hernias, uncircumcised. Rectal exam: negative without mass, lesions or tenderness.

Musculoskeletal: Bilateral knee exam –positive for crepitation on left knee, no swelling good ROM right knee -no swelling, no crepitation good ROM. Muscle strength symmetric 5/5 all groups. Positive for mild swelling in joint of all fingers

Neurological: reveals alert, oriented, normal speech, no focal findings or movement disorder noted. Gait regular, no involuntary movements. Cranial nerves II-XII grossly intact, DTR’s intact

Skin: normal coloration and turgor, has benign small moles on chest, has cluster of well-demarcated red plaques >20% BSA macules and coarse scales on lower back, elbows, and along hairline (Gladman, Shuckett, Russell, Thorne, & Schachter, 1987). Onycholysis, thickening, and pitting of fingernails (Mcgonagle, 2009).

ASSESSMENT:

Lab Test and Results:1. Skin biopsy and Periodic acid–Schiff–diastase (PAS-D) stain – positive for

epidermal hyperplasia2. RH factor – negative3. HLA-B27 – positive

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4. Nail culture using Potassium hydroxide (KOH) preparation – negative for nail fungus

5. Auspitz sign – positive (Bernhard, 1990)6. Radiology — “pencil-in-cup” phenomenon in both index fingers and right ring

finger (Siannis, Farewell, Cook, Schentag, & Gladman, 2006).7. Serum Urate – 5.2 mg/dL

Priority Diagnostics:A. Chronic Plaque PsoriasisB. Nail PsoriasisC. Psoriasis Arthritis

Differential Diagnosis (DDx):A.

a. Nummular eczemab. Seborrheic Dermatitisc. Atopic Dermatitis

B.a. Superficial fungal infectionb. Onychomycosisc. Lichen Planus

C.a. Rheumatoid Arthritisb. Reactive Arthritisc. Gout

Diagnoses/Client Problems:1. HTN, controlled2. Allergy to Penicillin (rash), salmon (anaphylaxis), peaches (lip itching),

controlled

References

Bernhard, J. D. (1990). Auspitz sign is not sensitive or specific for psoriasis. Journal of

the American Academy of Dermatology, 22(6), 1079-1081.

doi:10.1016/0190- 9622(90)70155-b

Gladman, D. D., Shuckett, R., Russell, M. L., Thorne, J. C., & Schachter, R. K. (1987).

Psoriatic arthritis (PSA) – An analysis of 220 patients. QJM: An International

Journal of Medicine, 62(238-241), 127.

doi:10.1093/oxfordjournals.qjmed.a068085

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Mcgonagle, D. (2009). Enthesitis: An autoinflammatory lesion linking nail and joint

involvement in psoriatic disease. Journal of the European Academy of

Dermatology and Venereology, 23(S1), 9-13. doi:10.1111/j.1468-

3083.2009.03363.x

Siannis, F., Farewell, V. T., Cook, R. J., Schentag, C. T., & Gladman, D. D. (2006).

Clinical and radiological damage in psoriatic arthritis. Annals of the Rheumatic

Diseases, 65(4), 478-81. doi:10.1136/ard.2005.039826

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