·         Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.

·         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 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 three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

·         Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?

·         Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.

·         Consider which of the conditions is most likely to be the correct diagnosis, and why.

Skin Condition-Sample Solution

Skin Comprehensive SOAP Note

Patient Initials: D.W.              Age: 32                                   Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC) (Graphic 2): “I feel less confident around people, including my husband, and I cannot go out to swim or wear bikini or crop tops.”

History of Present Illness (HPI): D.W. is a 32-year-old married African American woman who is 29 weeks pregnant and presenting at the clinic with complaints of increasing stretch marks in the past one and a half months. D.W. claims that she has lost confidence and self-esteem due to stretch marks. She denies feeling any pain in places of the abdomen but explains that the area might be “itchy” and that the lines are continuing to darken. She claims that since she cannot wear a bikini, crop top, or swimsuit, she would like anything to reduce the stretch marks. She indicates 0/10 for reported pain on the pain scale and denies fever. Over-the-counter cocoa butter was ineffective in eliminating or reducing stretch marks. She also thinks her stretch marks are related to weight gain.(Skin Comprehensive SOAPNote Essay)

Medications:

1. Prenatal Rx: 1 tablet daily
2. Amlodipine for HTN: 10 mg daily
3. Albuterol 90mcg for Asthma
4. Cortisone OTC for itching skin: Applies at least six times daily

Allergies: The patient reports she is allergic to dust, mold, pollen, and metronidazole

Past Medical History (PMH): The patient developed HTN at 24, asthma at four years, although controlled, and allergic rhinitis at age 7. She also has a past medical history of bacterial vaginosis, controlled with medication, and anxiety, which was managed without medication.

Past Surgical History (PSH): The patient underwent a surgical report of the umbilical hernia in 2006.

Sexual/Reproductive History: D.W. reports that she is married with one child, conceived at 26 years old. This is her second pregnancy. She is sexually active and not on birth control. She has one sexual partner, and together they go for regular STI testing every four months.

Personal/Social History: She is married and lives with her husband. She has an extended family comprising her mother, father, and two brothers.

Health Maintenance:

• She does not smoke
• She has one sexual partner
• She maintains a healthy diet, although she has experienced weight gain during pregnancy.
• She maintains healthy, supportive relationships with extended family members and friends.

Immunization History:

1. Covid vaccination
2. Influenza vaccine: 09/10/2019
3. Tdap: 07/4/2020
4. Measles and Rubella

Significant Family History: Her grandparents are dead. Her mother, 60, has a history of asthma and depression. Her father, 63, has a history of diabetes. The brothers are 35 and 27 years and have no medical history.(Skin Comprehensive SOAPNote Essay)

Review of Systems:

General: The patient reports fatigue over the last two months. She denies fever, syncope, lightheadedness with standing or ambulation, or chills. She reports sleeping 7-10 hours a day. She reports pervasive weight gain throughout her pregnancy, gaining about 10 pounds.

            HEENT

Respiratory: The patient reports a history of asthma. Denies a history of pneumonia, dyspnea, or hemoptysis. Reports dyspnea during vigorous physical activities like running or walking fast.

Cardiovascular/Peripheral Vascular: Denies chest pain, pressure, or discomfort. No palpitations or edema.

Gastrointestinal: The patient reports diet changes and feelings of nausea and vomiting. Denies diarrhea. No abdominal pain or blood. The patient reports experiencing constipation.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.

Musculoskeletal: The patient reports occasional muscle pain and weakness. Denies back pain and muscle or joint stiffness.

Neurological: Denies headaches, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

Psychiatric: The patient reports a history of anxiety, which she controls through meditation and physical exercise.

Skin/hair/nails: The patient indicates intermittent abdominal pruritus and scalp dandruff. The patient denies dermatitis in other body areas, spontaneous bruising, brittle hair, yellowing nails, or fungal infections. She reports itching, controlled using Cortisone OTC.(Skin Comprehensive SOAPNote Essay)

OBJECTIVE DATA:

            Physical Exam:

Vital signs: temp: 98.6F, B.P.: 100/65, P: 85, R.R.: 18, pain: 0/10 Ht: 5’5 feet, Wt.: 167 lbs., BMI: 27.8

General: Well-nourished and groomed AXOx4 32-year-old Black female, with appropriate mood, bright affect, and she is polite.

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Chest/Lungs: The patient’s heartbeat and rhythm are normal. The patient’s heart rate is normal, and capillaries refill within two seconds.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Abdomen: Normal active bowel sounds x4. No rebound tenderness X 4. Soft abdomen. No organomegaly. Fundal distance 30cm

Genital/Rectal: D.W. denies seeing a gynecologist routinely.

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. Muscle and back pain rated 0/10.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear.

Skin: Multiple stretch marks visible on the abdomen; color nigrae and albae. Noted skin xerosis to the abdomen, linea nigra vertically from the pubic bone to intermediary breast. No lymph nodes on palpation. Severe striae as indicated by TSS:> 18

Diagnostic results:

1. HCT – 36
2. WBC 5.89
3. Albumin – 3.7
4. Sodium – 135
5. Potassium – 3.7
6. AIC – 4.6
7. Fibrinogen – 215
8. Rh-negative

ASSESSMENT:

Primary diagnosis:

1. Striae gravidarum and Linea Nigra:

Stretch marks, or striae gravidarum, develop in roughly 50 to 90% of pregnant women as the uterus grows inside the abdominal cavity and separates the connective tissue beneath (Oakley & Patel, 2022). Early stretch marks are reddish-purple and develop as skin collagen is damaged and blood vessels enlarge. White or brown mature stretch marks result from melanocytes or pigment-producing cells dying from collagen remodeling. Stretch marks most frequently appear on the breasts, thighs, and abdomen (Dai et al., 2021). A woman’s skin type and family history affect the thickness of the striae. The weight gain D.W. experienced could explain the striae gravidarum, the first confirmed diagnosis, vividly noticeable in her abdomen.(Skin Comprehensive SOAPNote Essay)

Linea is a brown line on the abdomen, running from the umbilical to the symphysis pubis. Usually, around the second or third trimester of pregnancy, linea nigra symptoms manifest. Linea nigra hyperpigmentation is brought on by hormonal fluctuations in progesterone and estrogen during pregnancy, which lead the cells to stimulate melanocytes in the skin more (Barnawi et al., 2021). The skin’s increased melanocyte count is what makes the abdomen darker. Linea nigra is also vividly noticeable on D.W.’s abdomen, confirming it as the second diagnosis.(Skin Comprehensive SOAPNote Essay)

Differential Diagnosis

2. Linear Focal Elastosis: Uncertain etiology characterizes linear focal elastosis (LFE), an unusual benign acquired elastotic disease. Clinically, it is distinguished by several asymptomatic, raised, yellowish striae-like lines or bands dispersed horizontally throughout the lower and middle portion of the posterior trunk (Florell et al., 2017). The dermis’s focused increase in elastic fibers is the histological sign of LFE. The most common differential for LFE is Striae distensae.(Skin Comprehensive SOAPNote Essay)
3. Steroid-Induced Skin Atrophy: Topical steroids applied excessively on the skin might lead to steroid-induced skin atrophy. D.W.  exceeded the recommended dosage by using cortisone at least six times daily. Two to three times a day is recommended for using cortisone cream. When applied excessively, topical cortisone creams can produce lipocortin that blocks the enzyme phospholipase A2, resulting in erythema and striae distensae (Niculet et al., 2020). Protein catabolism and increased mitotic activity caused the enzyme phospholipase to develop, which helps to reduce inflammation. As seen in striae distensae, the atrophy brought on by excessive topical steroid use can elevate the skin, create vasoconstriction, and cause itching.(Skin Comprehensive SOAPNote Essay)
4. Cushing’s Syndrome: Cushing’s syndrome frequently presents as different skin disorders because of endogenous glucocorticoids and hypercortisolism. Although miscarriages are uncommon during pregnancy, they are highly likely when high blood pressure is present (Chaudhry & Singh, 2022). Striae distensae, a Cushing’s syndrome-related condition, results in dark, medium-sized to wide marks on the back, hips, thighs, and belly. Stretch marks are caused in patients with this illness by significant weight gain, high cortisol levels, and thin skin.(Skin Comprehensive SOAPNote Essay)
5. Pruritic Urticarial and Plagues of Pregnancy (PUPPP): PUPPP can develop at the end of the second trimester and continue into the third trimester in places including the belly, legs, and forearms (Ishikawa-Nishimura et al., 2021). D.W.’s belly shows extensive striae, which she describes as itchy. Target lesions on the abdomen might appear in PUPPP patients as itchy, edematous eczema lesions resembling stretch marks or a combination of stretch marks and eczema. Owing to PUPPP’s pathophysiology, it frequently goes undetected and eludes treatment during pregnancy. In PUPPP, Th2 cytokines such as IL-9 and IL-33 are upregulated. These cytokines target body parts with excess cortisol and cause hyperpigmentation, skin eruptions, and patchy white lesions with stretch marks.(Skin Comprehensive SOAPNote Essay)

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Barnawi, A. M., Barnawi, G. M., & Alamri, A. M. (2021). Women’s Health: Most Common Physiologic and Pathologic Cutaneous Manifestations During Pregnancy. Cureus, 13(7), e16539. https://doi.org/10.7759/cureus.16539

Chaudhry, H. S., & Singh, G. (2022). Cushing syndrome. In StatPearls [Internet]. StatPearls Publishing.

Dai, H., Liu, Y., Zhu, Y., Yu, Y., & Meng, L. (2021). Study on the methodology of striae gravidarum severity evaluation. Biomedical engineering online, 20(1), 109. https://doi.org/10.1186/s12938-021-00945-w

Florell, A. J., Wada, D. A., & Hawkes, J. E. (2017). Linear focal elastosis associated with exercise. JAAD case reports 3(1), 39–41. https://doi.org/10.1016/j.jdcr.2016.10.012

Ishikawa-Nishimura, M., Kondo, M., Matsushima, Y., Habe, K., & Yamanaka, K. (2021). A Case of Pruritic Urticarial Papules and Plaques of Pregnancy: Pathophysiology and Serum Cytokine Profile. Case reports in dermatology, 13(1), 18-22. https://doi.org/10.1159/000511494

Niculet, E., Bobeica, C., & Tatu, A. L. (2020). Glucocorticoid-Induced Skin Atrophy: The Old and the New. Clinical, cosmetic and investigational dermatology, 13, 1041–1050. https://doi.org/10.2147/CCID.S224211

Oakley, A.M., & Patel, B.C. (2022). Stretch Marks. In: StatPearls [Internet]. StatPearls Publishing.