Question

A 42-year old female presents with a complaint of a papule on her left forearm for the past 2 months that “looks funny”. Denies itching, scaling, drainage, or other complaints.

Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed, In SOAP format, list Pertinent positive and negative information, differential and working diagnosis, treatment plan, including Pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

Patient can be questioned about the following details:

1. Basic demographics of the patient like age, sex etc

2. Details about the lesion like

a. Duration and onset-sudden vs gradual

b. Any previous history of papules or other skin conditions.

c. Change - change in color, size etc

d. Associated symptoms - such as itching, tenderness, discharge etc

3.Patient should be asked about the following also:

A. Response to the treatment:A number of treatments may be initiated prior to consultations like calamine, otc, lotions etc.

B. Past medical history

C. Family history: such as melanomas

D. Allergies

E. Medication history

4.Physical examination:Note position, distribution(symmetrical or asymmetrical), size, color of the lesion and any associated tenderness.

Treatment of the patient in SOAP FORMAT has been shared in the image.