SOAP Note for Striae Gravidarum

Skin Comprehensive SOAP Note

Patient Initials: K.B. Age: 28 Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): Dark irregular bands on the abdomen since 2 months ago.

History of Present Illness (HPI): Kelly Bianca is a 28-year-old married, 28-week gestation African American female who presents to the clinic with complaints of dark irregular stretch marks that started about 2 months ago. While she states that the abdominal area can be itchy and the bands to continue to darken, she denies pain. She denies a history of stretch marks and would like something to minimize the bands since she has tried cocoa butter without any relief.

Medications: Benadryl 25mg before bed; Prenatal Rx: 1 tablet daily; Cortisone OTC: applies nearly 5 times daily for itching.

Allergies: No known allergies.

Past Medical History (PMH): Denies any chronic diseases.

Past Surgical History (PSH): None.

Sexual/Reproductive History: Heterosexual. She is currently sexually active with her husband. She denies using oral contraceptives; no cramping; no excessive bleeding.

Personal/Social History: She is married and has been living with her husband for 3 years. Denies use of any drugs at home. Denies drinking caffeinated products. She reports having a good support system at home and works as a sales manager at a nearby fast food restaurant.

Health Maintenance: Denies any type of intimate partner abuse. She reports getting at least 8 hours of sleep daily. She reports having regular hospital visits for checkups.

Immunization History: She is up-to-date on immunizations with the last tetanus immunization on 12/2021. Reports refusing COVID-19 vaccinations.

Significant Family History: Her mother and father are alive and aged 50 and 55 years respectively. Her mother has a history of anxiety and depression while her father has no significant medical history. She has two younger siblings i.e. brother (25 years) and sister (23 years) with no significant medical history. Her 70-year-old paternal mother is alive with a history of hypertension while her paternal father died from a car accident aged 75 years.

Review of Systems:

General: Alert and fully oriented. Reports being fatigued over the past two weeks. Denies fever and weakness. Reports change in appetite and weight gain.

HEENT: Head: Denies headache or any head injuries. Ear, Nose and Throat: Denies hearing loss; no ear drainage. Reports normal breathing; denies nose pain. Denies sore throat. Eye: No vision loss.

Respiratory: Denies history of asthma or any respiratory illnesses.

Cardiovascular/Peripheral Vascular: Reports occasional nausea.

Gastrointestinal: Reports itchiness in the abdominal area. Denies pain in the abdominal area. Denies eructation or excessive flatulence.

Genitourinary: No breast pain or masses.

Musculoskeletal: No joint pain; tenderness or swelling; Reports back pain over the past 2 months. Denies gout.

Neurological: Denies problems with memory. No headaches.

Psychiatric: Denies depression or anxiety.

Skin/hair/nails: Reports her nails have been healthy since pregnancy. No hair loss. Reports dark irregular bands on the abdomen. Denies having skin problems in any other area of the body.

OBJECTIVE DATA:

Physical Exam

Vital signs: B/P: 134/88; Temp 96F (oral); Pulse 77bpm; Wt: 185 pounds; Ht: 5 feet 5 inches; RRR: 20; Fetal Heart Rate: 127bpm. BMI: 32.

General: Alert and oriented. Fully understands the changes in the body. Mood appropriate and well-groomed.

HEENT: No dandruff. Face symmetrical. Skull is normal. Eye color brown. No nasal discharge. No ear drainage. No nose pain. No sore throat. Lips dry.

Neck: Full range of motion in all directions.

Chest/Lungs: Clear breathing sounds. No difficulty in breathing.

Heart/Peripheral Vascular: No heart murmur when breathing. Negative for heart pleural rubs or gallops. No peripheral edema in legs.

Abdomen: Dark irregular bands. Reports occasional itchiness. No tenderness. Normal bowel sounds.

Genital/Rectal: Patient declined. Routine check-ups by a OB/GYN.

Musculoskeletal: ROM intact in all four extremities.

Neurological: Alert and fully oriented.

Skin: Stretch marks on the abdomen. Dark irregular bands.

Diagnostic results: UA: Negative for protein, nitrate, blood or leukocytes. HCT: 35. HGB: 11.9. Creatinine: 0.9. Potassium: 3.5. Sodium: 135. Fasting glucose: 80.

ASSESSMENT:

Primary Diagnosis: Striae gravidarum. According to Wollina & Goldman (2017), this is a common condition affecting between 50% and 90% of pregnant women. The condition is characterized by irregular bands on the abdominal area that occur in different colors including black or dark grey (striae nigrae), purple or pink (striae rubra), or white (striae alba). This patient could be diagnosed with this condition because she exhibits striae nigrae on the abdominal area. In addition, the patient has reported higher maternal weight gain, which is one of the predisposing factors for this condition (Brennan, Clarke & Devane, 2016). The patient’s BMI of 32 is also an indicator of striae gravidarum since being overweight increases susceptibility to this condition, especially in the third trimester of pregnancy (Farahnik et al., 2017).

Differential Diagnosis

Cushing’s Syndrome: While this condition is rare in pregnancy, it is characterized by dark bands or marks on thighs, back, abdomen, and hips. Mrs. Bianca could be diagnosed with this condition because of the dark irregular bands on her abdomen and excessive weight gain (Oakley & Patel, 2021). However, she has no other skin conditions that would necessitate this diagnosis, which always manifests as other skin problems.