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Lab Assignment: Differential Diagnosis for Skin Conditions


Week 4

Skin Comprehensive SOAP Note Template


Patient Initials: _xx_____      Age: __xx_____                                 Gender: ____xx___





Chief Complaint (CC): Patient c/o rash number three to from the chest, back to the abdomen. (5).

History of Present Illness (HPI): JM is a 50-year-old female who is having numerous small irregularly shaped papules which are red in color. The papules are found in the anterior chest and the part of the abdomen and the papules started to appear in the last 2 months with the onset that was very gradual. JM is denying associated symptoms, alleviating factors as well as the aggravating elements. Over the last 2 months, there has been an increase in the papules. The papules are not painful and the pain rate is 0/10 without itching and no treatment has been tried recently.


95 mg of Colace that is taken every day

15mg of Cetirizine taken every day

50mg table of Senna taken every day.

Acetaminophen 600mg taken two times a day.

Allergies: The patient has no allergies

Past Medical History (PMH): The patient has constipation which she often controls through the use of fiber supplements as well as other medication (Brugha, 2013).

She had chicken pox when she was 10 years old and this was treated successfully.

Past Surgical History (PSH): She has undergone an appendectomy at the age of 9.

Sexual/Reproductive History: The patient is sexually active with a one sexual partiner.

Personal/Social History: Not a smoker at all.

She does not use illicit drug.

Is married to one husband and is sexually active.

She takes 2 liters of wine every week.

Health Maintenance: She is actively participating in sports and physical activities. Her hobbies include swimming. She also ensures she takes balance diet.

Immunization History: She has been given all childhood vaccines

In 2019, she received her last vaccine which was flu vaccine.

Significant Family History: The mother is diabetic but is not taking insulin at the moment.

Has a 10 years’ son which is allergic to dust and has asthma.

The father has a history of high blood pressure and depression.

The brother is asthmatic but the condition is properly controlled.

Review of Systems:

General: She does not show any weight loss, fever or night sweats.           

HEENT: Denies: vision problems, headaches, hearing problems, dizziness, bleeding gums, ulcers, ear pain, mouth sores or changes in smell. Her breast has no lumps, discharge or tenderness.

Respiratory: The patient has no cough, shortness of breath or sputum.

Cardiovascular/Peripheral Vascular: Negative palpitations, shortness of breath, chest pain or murmurs

Gastrointestinal: the patient denies vomiting, abdominal pain, constipation, nausea, diarrhea, abdominal pain, changes in bowel movement.

Genitourinary: Negative for dribbling, blood in urine, dysuria, incontinence. Has no history of sexually transmitted illness.

Musculoskeletal: Positive for tenderness, redness and swelling in the right hand and this is minimizing the movement of her hand.

Neurological: Denies dizziness, numbness, consciousness or dizziness.

Psychiatric: Denies a past history of depression or mental health condition. Has no issues with sleeping or concentration patterns? Has no previous suicidal thoughts.


Skin/hair/nails: The skin has papules and the hair is black. The nails look strong and healthy


Physical Exam:

Vital signs: Height: 5’7, Weight: 200 pounds, BMI: 31.2-the patient is obese.

BP: 118/66, HR 85, Pulse Ox: 97% RA, Temperature: 96.5F oral, Respiratory Rate: 16, Pain 0/10

General: Denies fevers, chills, night sweats, weight changes. The well is properly groomed

HEENT: PERRL, EOMI, nasopharynx with mildly visible congestion, discharging clear nasal discharge. Has no epistaxis.

Neck: No bruit nor lymphadenopathy

Chest/Lungs. The lungs are allowing good movement of air without restriction. Denies shortness of breath and the upper as well as the lower lobes are clear bilaterally

Heart/Peripheral Vascular: The heart beats are normal without murmur and there is good S1 and S2 audio

Abdomen: The abdomen is soft but without tenderness. The most recent BM was done today. No blood in the stool nor diarrhea

Genital/Rectal: In the genital area there is no presence of lesions. Urination is normal without difficulty and the urine is free from blood.

Musculoskeletal: There is total ROM in every joint. Denies pain in the joints. There is equally distributed strength in the movement, +6 grip of the hands.

Neurological: The patient is always alert and properly oriented at a rate of 5. The patient is not dizzy nor weak.

Skin: There are some brightly red papules that are about 4mm on the chest and the abdomen. There is no tenderness, peeling, dryness, excess warmth or swelling of the skin. There is to evident masses of clubbing or cyanosis in the skin.

Diagnostic results:

  1. She has some allergies that comes seasonally.
  2. Some small degree of constipation.
  3. Slight headaches.


Lab Tests & Results: WBC 11,000, Hgb 11.2

Biopsy: The results are not yet out.

Labs: There is a full blood count.

Diagnostics: The skin has some signs of lesion biopsy.

Diagnosis Rationale:

When some people attain the age of 30, they might start developing some lesions on the body especially the chest and abdomen called cherry hemongioma (Abeck, 2020).  At some point, cherry hemongioma are inherited genetically (Wertz, 2013). This condition often develops in the elderly people and can gro to 5mm in size. They come in different sizes and color and sometimes they are hard (Otlewska, 2018).  Sometimes, a patient with this kind of condition can start bleeding in the lesions.






Abeck, D. (2020). Senile Angiome. Häufige Hautkrankheiten in der Allgemeinmedizin, 151-153.

Brugha, R. (2013). Chapter-12 skin and rashes. Paediatric Clinical Examination, 209-226.

Otlewska, A. (2018). The coexistence of somatic and mental ilnesses. Medycyna Ogólna i Nauki o Zdrowiu24(1), 54-58.

Wertz, P. (2013). Current understanding of skin biology pertinent to skin penetration: Skin biochemistry. Skin Pharmacology and Physiology26(4-6), 217-226.





Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.

This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.

Learning Objectives

Students will:

  • Apply assessment skills to diagnose skin conditions
  • Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
  • Analyze dermatologic procedures to include skin biopsy, punch biopsy, suture insertion and removal, nail removal, skin lesion removal


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