Skin Assessment SOAP

1 Skin Assessment SOAP Patient Information: R.C, 28-year-old male, Asian-American Subjective CC. “I have dry, cracked skin and itchy red patches that bleed easily.”

HPI: K.C, A 28-year-old male, came to the ER this morning complaining of dry, cracked skin and painful red patches that bleed easily once scratched. The client clarified that the condition had lasted for a week before the visit. He also noted that the scaly patches are not responding to normal hygiene practices such as cleaning with soap and water.

Location: skin Onset: four days ago Character: painful, itchy, red patches on the skin Associated signs and symptoms: pain and itching Timing: N/A Exacerbating/relieving factors: not pointed out Severity: 5/10

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2 Medications: currently, the client is not on medications Allergies: The client does not have known allergic conditions PMH: Negative for arthritis, high blood pressure, and diabetes Immunization: The client is fully vaccinated; last tetanus jab December 2017.

Fam Hx: parents are alive with no major health problems Soc Hx: he drinks alcohol during social occasions, does not use substances or smoke cigarettes.

ROS: GENERAL: No fever and chills. He denies sweating at night, changes in appetite, and noteworthy changes in weight.

HEENT: Head: He denies observable health injuries Eyes: No sight abnormalities such as blurred vision and double vision Ears: No mucus production and runny nose; Nose: no ear pain and abnormal discharge.

Throat: no sore throat and sinus inflammation.

SKIN: he reported dry, cracked skin and red patches on the scapular and arms CARDIOVASCULAR: He denied chest pain, palpitations, and edema RESPIRATORY: No shortness of breath GASTROINTESTINAL: No bloody stool, negative for abdominal symptoms.

GENITOURINARY: No pain, burning, and urinary retention NEUROLOGICAL: No dizziness and numbness MUSCULOSKELETAL: No joint pain, stiffness, and a reduction in range of motion HEMATOLOGIC: No nose bleeding and anemia

3 LYMPHATICS: No inflamed tonsils and other lymph nodes PSYCHIATRIC: No anxiety disorder ENDOCRINOLOGIC: No heat intolerance, thirst, and extreme sweating Objective VS: BP 131/94; P 87; RR 19; T 97.8; 02 99%, Ht 5’5” Wt 167lbs.

General— The client does not demonstrate anxiety and distress HEENT Head: No visible cranial injuries or deformities, Eyes: No pupil infections noted; Ears: the ear canals do not have abnormal discharge, Nose: the nostrils are open, Neck: No signs of the thyromegaly and erythematous throat.

Skin: Red patched observed on the skin; dry, cracked scaling spots noted on the arms and the scapular Cardiovascular- S1/S2 present, Abnormal sounds like gallops not heard.

Gastrointestinal — ordinary bowel sounds detected, No distention or obesity observed.

Pulmonary- auscultation detects normal lung sounds. No excessive mucus and labored breathing Musculoskeletal: The client has a normal range of motion; no swollen joints were noted Diagnostic tests: Skin sample examination under a microscope Assessment Differential Diagnoses Atopic Dermatitis 9L20.9)

4 In atopic dermatitis, the skin appears as red to brownish dry patches. These patches mostly occur on the body, hands, and feet. The small, raised bumps may leak fluids that crust over the patches (Weller, 2015).

Seborrheic Dermatitis (L21. 9) This condition occurs in oil-rich surfaces of the skin such as the nose and the eyebrows. It also occurs on the scalp (Garg, 2020). The symptoms include red or white scaly patches on the scalp, pinkish plaques and scaly redness.

Subcorneal Pustulosis Dermatosis (L13.1) Pus-filled blisters are the common symptoms of SPD (Weller, 2015). They appear as small round swelling that irritates the skin leading to inflammation.

Primary diagnosis Psoriasis ICD-10-CM L 40 The client has psoriasis skin disease characterized by itchy red patches on the skin (Elston, Ferringer & Ko, 2019). The red patches, which are dry and cracked, bleed easily when scratched.

Plan/Therapeutics Tests - Skin biopsy- examining a skin sample under a microscope Medication -

25mg Soriatane 1 tab daily

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Topical Cream- Desonide 0.05- %,

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Topical cream – Calcipotriene twice per day (Barnhill et al., 2019)

Non-medication treatments

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Hygiene – regular body washing with mild soap and water

Education - The client to avoid irritants such as perfumes and strong antiseptic agents - The client to consume healthy foods and sufficient fluids, which are essential for skin integrity (Bonifant & Holloway, 2019) Follow-up- client to visit the facility after two weeks Self-assessment 

Interaction with the client was satisfying since he reacted appropriately to clinical interview questions

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The client was cooperative

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A biopsy test was conducted whereby a skin sample was observed under a microscope.

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The clinician integrated pharmacological and non-medication interventions into the treatment plan.

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The client was given topical creams and Soriatane, which are approved for treating psoriasis

6 References Barnhill, R. L., Crowson, A. N., Magro, C. M., Piepkorn, M., Kutzner, H., & Desman, G. T. (2020). Barnhill's dermatopathology. McGraw-Hill, Bonifant, H., & Holloway, S. (2019). A review of the effects of aging on skin integrity and wound healing. British Journal of Community Nursing, 24(Sup3), S28–S33. https://doi.org/10.12968/bjcn.2019.24.sup3.s28 Elston, D. M., Ferringer, T., & Ko, C. J. (2019). Dermatopathology. Elsevier Garg, S., (2020). Clinical dermatology. CBS Publishers & Distributors.

Weller, R. (2015). Clinical dermatology. John Wiley.