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Differential Diagnosis
Alvin L. Johnson
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NURS 6512
Advanced Health Assessment
Walden University
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Week 4Assignment
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2
Differential Diagnosis
SOAP NOTE
Differential Diagnosis for Skin Condition
Skin Condition Picture #4
Patient Initials: RJ
Age: 33
Gender: F
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SUBJECTIVE DATA:
Chief Complaint (CC): Complains of pain under right armpit with a type of skin growth.
History of Present Illness (HPI): Renee’ Johnson is a 33-year old African-American female
who presents today with a chronic complaint of pain to right axilla. She reports to the pain
beginning approximately four weeks prior to the visit and noticed the pain while bathing
underneath the right axillary. Upon completion of her bath, she observed a small growth in this
same area. She reports doing a self-examination and noticing a “skin growth” to the upper part
of the area with no hemorrhaging but slight redness when it has been irritated. She reports the
need to keep the axilla areas shaved due to the hair surrounding the skin growth wrapping around
it at times an pulling it. There are also times when it gets caught on her clothing and is pulled and
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causes pain. She does not complaint of any itching to the site or surrounding area. She has
attempted to remove the skin growth by tying dental floss to the top of it without success. She
Medications:
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reports the severity of pain at the moment to be 3/10.
1) Neurontin 300 mg TID
2) Zoloft 25 mg orally daily.
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3
Differential Diagnosis
3) Hydrocodone/Acetaminophen 7.5/325 mg Q4H PRN
Allergies: No Know Drug Allergies
Past Medical History (PMH): Fibromyalgia diagnosis three years ago. Treatment occurs daily
outside of admission to a medical treatment facility. Prescribed medications to treat the
condition.
Past Surgical History (PSH): Cholecystectomy 2004.
Heterosexual
G4P3A1
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Sexual/Reproductive History:
Non-menstruating
Personal/Social History: She denies tobacco, ETOH, or illicit drug use.
Immunization History: Her immunizations are up to date. Her last Tdap was in 2010. She
received the Influenza vaccine in October 2018. Currently, she does not meet the criteria for
receiving the pneumococcal vaccine.
Significant Family History:
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Mother, age 62, has a history of Non-insulin dependent diabetes mellitus since 2015. It is
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controlled with diet and exercise. She also has a history of gout and currently takes Colchicine
2.4 mg orally daily. Father, age 64, has a history of hypertension and takes Zestril 20 mg orally
daily. Maternal grandfather, deceased, died from prostate cancer. Paternal grandmother,
deceased, died from breast cancer.
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Differential Diagnosis
Lifestyle
She is housewife and married with for children and a granddaughter. She lives in a rural
environment with good transportation. She is a college graduate and co-owns a small business
with her husband. She is financially stable with the business receiving $75,000 annually. She
does have a primary care provider; however, he is currently out of the country.
Review of Systems:
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General: Patient denies fever, fatigue, or poor appetite.
HEENT: No visual deformities to her head. No complaints of headache. Patient wears glasses
for reading only. PERRL. No difficulty hearing observed and also no excessive cerumen
observed to ear canal. Tympanic membranes are pink with land mask’s visible. No nasal
draining seen. No redness or irritation observed to throat. Oral mucosa is pink and moist.
Neck: No complaints of pain upon palpation to lymph nodes. No inflammation or visual
deformities. Supple with full range of motion.
Breast: Denies tenderness/discomfort. Does not report any changes to breast tissue. Has no
history of breast cancer. Breasts are symmetrical.
Respiratory: No SOB, cough, or congestions. Upon auscultation, lung sounds are bilaterally
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clear to upper and lower lobes. Respiration are even and non-labored.
and WNL.
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CV: Regular rate and rhythm without presence of gallops or murmurs. Blood pressure normal
GI: Abdomen soft and nondistended. Bowel sound present to upper and lower quadrants. No
tenderness upon palpation.
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Differential Diagnosis
GU: External genitalia WNL without presence of lesions. No foul odor or discharge. No history
of STDs. She is continent of bowel and bladder control.
MS: She has not complaints arthritis of muscle pain. Full active range of motion to upper and
lower extremities.
PSYCH: She has been diagnosed with depression since the diagnosis of Fibromyalgia. She is
prescribed Zoloft 25 mg orally daily.
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NEURO: Complains of periodic headaches related to the diagnosis of Fibromyalgia. She is
prescribed Hydrocodone/Acetaminophen 7.5/325 mg Q4H PRN.
INTEGUMENT/HEME/LYMPH: Skin growth to right axilla. No other skin abnormalities
observed. Keeps skin moistened daily by using lotion.
ENDOCRINE: No abnormalities in this area. No hormone therapy at this time.
ALLERGIC/IMMUNOLOGIC: No history of allergies and no immune deficiencies.
OBJECTIVE DATA
PHYSICAL EXAM: B/P 120/80, right arm, sitting, regular adult cuff; P 72 and regular; T 98.6
orally; RR 14 and non-labored; Wt: 130 lbs.; Ht: 5’ 3.
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General: Alert, interactive, and well nourished. No appearance of distress.
HEENT: No visual deformities to her head. No complaints of headache. Patient wears glasses
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for reading only. PERRL. No difficulty hearing observed and also no excessive cerumen
observed to ear canal. Tympanic membranes are pink with land mask’s visible. No nasal
draining seen. No redness or irritation observed to throat. Oral mucosa is pink and moist.
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6
Differential Diagnosis
Chest/Lungs: Chest is symmetrical. Bilateral lungs sound clear to upper and lower lobes.
Heart/Peripheral Vascular: heart noted with regular rate and rhythm. Blood pressure WNL.
ABD: Abdomen soft and nondistended. No tenderness noted.
Genital/Rectal: Genitalia intact, externally.
Musculoskeletal: AROM to upper and lower extremities. No history of trauma or fractures.
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Neuro: Responds appropriately for ages. Able to move all extremities without difficulties.
Skin/Lymph Nodes: No signs of edema or cyanosis. No nodes observed upon palpation.
ASSESSMENT:
LAB TEST AND RESULTS:
SAO2%: 95% on room air.
CBC: WBC 5,000; RBC: 14 GM/DL
DIFFERENTIAL DX:
1) Cutaneous Tag (Acrochordon)
2) Cutaneous Horn
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3) Seborrheic Keratoses
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DIAGNOSIS/CLIENT PROBLEM
Cutaneous Tag (Acrochordon) is likely to be the diagnosis for this patient. A cutaneous tag is
small and soft and is attached to the body by a narrow stalk of skin and is not necessarily
pigmented (J. Ball, et al. 2015). These are flesh colored and can be found on the neck, armpits,
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7
Differential Diagnosis
or groin (John Hopkins. 2019). A cutaneous tag can also be very irritating to the individual and
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can be found in middle-aged adults (G. Cole. 2018).
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Differential Diagnosis
References
Ball, Jane et. al. (2015). Seidel’s Guide to physical examination (8th ed.) St. Louis, MO: Elsevier
Mosby.
Cole, Gary (2018). Skin tag. Retrieved from
https://www.medicinenet.com/skin_tag/article.htm#skin_tag_facts.
John Hopkins (2019). Other benign skin growths. Retrieved from
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https://www.hopkinsmedicine.org/health/conditions-and-diseases/other-benign-skin-growths.
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