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
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:...
…The patients
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
Cushings 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.
Linea Nigra: This is a possible differential diagnosis for the patients symptoms because of dark irregular bands on the abdomen. Linea Nigra is caused by hormonal changes in cells during pregnancy resulting in darkening of the abdomen. However, the patient is not necessarily experiencing darkening of the abdomen but dark irregular bands.
Steroid-induced skin atrophy: This is a possible differential diagnosis that is usually caused by overuse of topical steroids (Oakley & Patel, 2021). She could be diagnosed with this condition…
