Skin Condition Soap Note
This SOAP note:
Chief Complaint: A 14-year-old female comes in with her mom with an annular rash on the left lower leg for 2 days. Mom states they went hiking this weekend.
Definite diagnosis: LYME DISEASE
Differential diagnosis:
1. Lyme Disease
3. Herald Patch of Pityriasis Rosea
Solution
Lyme Disease
Student’s Name
Institutional Affiliations
Patient Initials: L. A. Age: 14 years Gender: Female Race: White
Subjective
Chief Complaint (CC): “I have an annular rash on the left lower leg.”
History of Present Illness (HPI): Patient L. A is a 14 year old female who has come to the clinic with her mother. As reported by the patient, she has an annular rash on the left lower leg. The rash started 2 days ago. Her mother states the patient went hiking with her friends last weekend. The rash appears red. The redness reduces during cold weather and exacerbates during hot weather. The rash is not associated with any form of pain.
Past Medical History (PMH): Patient L. A. had a severe flu 6 years ago. However, she was not hospitalized but her condition was managed at home. Since then, she has not been diagnosed with a serious medical condition.
Immunization: As per L. A.’s medical records, she was vaccinated as required. Up to this time, she has received vaccines for a number of diseases including; measles, mumps, rubella, influenza, hepatitis B, rotavirus, influenza, and varicella in their correct doses. She still has some immunization in the coming months.
Allergies: L. A. is allergic to fish products. However, the mother states that there are no known drug allergies.
Medications: None.
Past Surgical History (PSH): L. A. has never undergone any surgery.
Family History: The patient’s mother denies a family history of any serious medical conditions. None of her family members has ever been diagnosed with conditions such as stroke, heart attack, diabetes, and skin disorders.
Social History: L. A. takes part in sports and she likes to go hiking with her friends. She denies having a boyfriend. The patient’s mother describes her as a respectful and obedient girl.
Review of Systems:
General: No fever, no chills, has a good appetite, and no significant changes in weight reported.
HEENT: L. A. denies a history of head injury. She denies having ear infections and states that she can hear properly. L. A. denies blurred vision or eye injury. She denies issues with her nose and throat.
Skin: L. A. reports that she has an annular rash with erythema on the left lower leg.
Respiratory: L. A. denies shortness of breath and breathing difficulties. She also denies a cough.
Cardiovascular: Denies chest pain and chest congestions.
Gastrointestinal: Denies abdominal issues.
Musculoskeletal: L. A. has a normal gait. Denies joint-related issues and has not experienced any problems with movement.
Neurologic: L. A. denies headaches or dizziness.
Objective
Vital Signs: Height= 48 inches, Respiratory rate=16, Heart rate=96 bpm, temperature=35 degree Celsius.
General: L. A. is well-groomed, neatly dressed, and looks healthy. She is attentive and maintains eye contact during discussions.
HEENT: The head is normocephalic with no evidence of physical injury. The ear canal is clear with no evidence of blockage. Her eyes are sensitive to changes in light intensity. The mucous membrane of her nasal mucosa appears moist, hairy, and pink. The throat is clear, no lesions, and no erythema.
Skin: The skin on her left leg has an annular rash. The rash is erythematous.
Chest/Lungs: The left and right lungs are correctly positioned. No wheezing is heard. The patient can comfortably exhale and inhale gases as evidenced by the diaphragm rhythm. No crackles, breath sounds can be heard in all regions of the chest.
Cardiovascular Peripheral/Vascular: No murmurs, no gallops or bruits auscultation. Peripheral pulses are present.
Musculoskeletal: No pain in the joints on palpation. The patient can move his joints with ease. No areas of abnormally increased warmth.
Laboratory tests: Blood tests/serology; histology.
Assessment:
Definite diagnosis: Lyme disease
Differential diagnoses:
- Lyme disease
- Tinea corporis
- Herald Patch or Pityriasis Rosea
Rationale
Lyme Disease
Lyme disease is a tick-borne skin disease that is commonly diagnosed among populations worldwide. Some ticks harbor bacteria of the species Borrelia burgdorferi that causes Lyme disease. The pathogen is transmitted to humans through a tick bite (Fallon & Sotsky, 2017). The early stages of the disease are confirmed by the presence of a localized rash with a red ring or erythema around it. The erythema migraines are evidence of a tick bite that must have occurred recently.
Some patients may present with other symptoms including myalgia, malaise, fever, and headache during the early stages of the disease. Patients experience severe symptoms after the bacteria travels through the blood from the site of the bite to body tissues. Being an inflammatory condition, Lyme disease usually affects several body systems (Skar & Simonsen, 2021). The patient’s condition meets the characteristics of Lyme disease as evidenced by the presence of an annular rash with an erythema. With time, the rash may increase in size and may also spread to other parts of the body when not managed or treated.
Tinea Corporis
Tinea corporis is a common disease condition among populations. The condition is characterized by the presence of an itchy red rash on the areas of exposed skin such as the neck, legs, and upper arms. On physical examination, either single or multiple lesions may be observed at the site of the rash. The lesions may appear as plaques and patches (Yee & Al Aboud, 2021). While the rash experienced by patient L. A. is erythematous, it is not itchy and does not appear as plaques and patches, a factor that rules out tinea corporis.
Herald Patch or Pityriasis Rosea
Pityriasis rosea is a skin disorder that is characterized by papulosquamous plaque. The condition starts as a large red scaly plaque hence the name ‘herald patch’. It is commonly observed in areas of exposed skin including the neck, upper arm, and legs. The initial plaques usually form scaly lesions which also erupt to add to the size of the plaque. Typical scaling occurs following the eruption of these lesions. Other common symptoms in patients with Herald patch include; a sore throat, fever, and gastrointestinal disturbance (Mahajan et al., 2016). Patient L. A dose not present with these symptoms and her rash is not characterized by a large erythematous scaly plaque.
Plan
Diagnostics: To accurately diagnose Lyme disease, the clinician must start by collecting a comprehensive patient history. People who recently traveled to tick-prone areas are highly likely to be bitten by ticks that harbor Borrelia burgdorferi. Serology or blood tests should be conducted to confirm the presence of the infection in the blood. Histology should be performed together with serology to enhance the diagnosis. Plasma cells, lymphocytes, and histiocytes are usually present in the perivascular cellular infiltrate when histology is performed (Skar & Simonsen, 2021). Knowledge of how these cells appear is a great determinant of whether an accurate diagnosis will be made or not.
Medications: Pharmacologic interventions have been found to be effective in the management of Lyme disease. The disease can be treated using antibiotics that are administered either orally or intravenously (Skar & Simonsen, 2021). Drug dosages are usually selected based on the age of the patient. Since patient L. A. is an adolescent, she should be given 40 mg of doxycycline taken for 2 to 3 weeks. This medication should be taken orally.
Other alternative oral medications that can be administered include; 250 mg of Amoxicillin taken once a day for 2 weeks or 250 mg of cefuroxime taken twice a day for 14 days (Fallon & Sotsky, 2017). The clinician should evaluate the patient after 2 weeks to determine whether there is a need to replace the oral medication prescribed earlier (Rosenthal et al., 2021). Intravenous antibiotics can be considered in case the patient expresses concerns with oral consumption of the oral drugs.
Patient Education: The clinician should educate the patient and her mother about medication adherence. Besides, the patient should be educated about the cause of Lyme disease and its risk factors. They should be informed about the side effects of the prescribed medications and how to manage them (Mattingly & Shere-Wolfe, 2020). The patient and her mother should be advised to contact the clinic in case L. A. develops severe drug reactions.
Health Promotion and Disease Prevention: The patient must take appropriate prevention measures to prevent future occurrences of Lyme disease. She should also implement actions that will promote good health to enhance the recovery process. Eating a healthy diet, and cleaning the affect area, is an appropriate health promotion strategy to implement. The prevention measures that the patient should consider include; avoiding bushy areas where ticks are likely to be found, using insect repellant, and wearing long-sleeved clothes (Fallon & Sotsky, 2017). Untreated Lyme disease may lead to other serious complications such as inflammation of the brain and the heart.
Follow-Up Care: The clinician should conduct patient follow-up after every four weeks to evaluate the patient and establish how she is responding to medications.
References
Fallon, B., & Sotsky, J. (2017). Conquering Lyme Disease: Science bridges the great divide. New York: Columbia University Press.
Mahajan, K., Relhan, V., Relhan, A. & Garg, V. (2016). Pityriasis rosea: An update on etiopathogenesis and management of difficult aspects. Indian Journal of Dermatology, 61(4), 375-384. doi: 10.4103/0019-5154.185699
Mattingly, T. J., & Shere-Wolfe, K. (2020). Clinical and economic outcomes evaluated in Lyme disease: a systematic review. Parasites Vectors, 13, 341. https://doi.org/10.1186/s13071-020-04214-y
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Skar, G. L., & Simonsen, K. A. (2021). Lyme disease. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431066/
Yee, G., & Al Aboud, A. M. (2021). Tinea Corporis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544360/