Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note

Patient Initials: ___A.B.____             Age: ___56____         Gender: ___Male____

SUBJECTIVE DATA:

Chief Complaint (CC): The patient presented to the clinic with a complaint of unrelenting sore throat, and the presence of an irregular dark spot on the skin of the forearm. The spot keeps changing in shape and size.Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

History of Present Illness (HPI): Patient A.B is a 56 year-old Caucasian male who came in with a sore throat that was not responding to treatment and an irregular and discoloured lesion on the forearm. These symptoms started four weeks before and have been persistent ever since. The throat is painful and the discoloured lesion is irregular and expanding. The sore throat is aggravated by spicy foods and slightly relieved by taking cold fluids. He was treated previously with amoxicillin 500 mg TDS for one week but there was no response. He rates the severity of the sore throat, the lesion, and his discomfort at 6/7.Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Medications:

1. Dyclonine (Cepacol) spray daily
2. Acetaminophen 500 mg PRN
3. Betamethasone topical cream applied TDS

Allergies:

1. NKDA
2. No allergies to food and food products

Past Medical History (PMH):

1. Hypertension that is currently well controlled.
2. Pneumonia – admitted for one week in 2015.
3. PUD on H2 receptor blockers, currently with no symptoms.
4. Lymphogranuloma venereum in 1999 (treated) and Donovanosis in 2001 (treated).Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Past Surgical History (PSH):

1. Herniorrhaphy (inguinal) in 1992.
2. Splenectomy in 2005.

Sexual/Reproductive History:

1.  
2. Vasectomy (2000).

Personal/Social History:

He denies smoking or a history of the same. Also denies etoh or the use of any substances of abuse. Patient can carry out ADLs unassisted and is able to do isotonic aerobic exercise (daily walking in the park) as a routine. He does not eat meat but consumes sufficient amounts of fresh fruits and vegetables. He routinely takes three meals in a day but rarely eats or drinks anything in-between, except water.Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Immunization History:

His immunizations are up to date. Last booster Tdp received in 2009. Influenza and pneumococcal vaccines received in February 2020.

Significant Family History:

He has one elder sibling – a sister who is married with a grown son. She has type II diabetes mellitus dx at the age 40 years. Both of his parents are deceased from natural causes. His only daughter is healthy and currently living in another state. Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Lifestyle:

Patient A.B. is a retired educator currently relying on his pension. He is however financially stable and can meet his needs. He is a divorcee (2007) living currently in a suburban neighborhood with good amenities and security. He is close to his elder sister whose children also visit him regularly as is his own daughter.Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.

Review of Systems:

General: Reports fatigue and some weakness though denies fever, chills or diaphoresis at night. He denies any recent weight changes.

HEENT: No short-sightedness, no hearing loss, otorrhea or tinnitus, and does not wear glasses or hearing aids. His last ear examination was 8 months ago. He denies photophobia, excessive tearing or diplopia. Denies having epistaxis and confirms that his sense of smell is intact. He denies nasal polyps, rhinorrhea, or a history of allergic rhinitis. He denies gingivitis, oral ulceration, or bleeding of the gums. He does not have any dental appliances and his last dental check-up was six months ago. He however accepts pain in the throat (sore throat) that is persistent and causes dysphagia.Differential Diagnosis for Skin Conditions: Comprehensive SOAP Note.