Answer

Comprehensive Soap Note: Skin Tag (Acrochordon)

Comprehensive SOAP Note

Patient: Ms. Jones                              Age: 28 years                                      Gender: Female

SUBJECTIVE DATA

Chief Complaint (CC): “Painful skin tag” (Image 4).

History of Presenting Illness (HPI): Ms. Jones is a 28-year-old obese African American single woman who presents to the clinic with a painful skin tag. She came to the clinic to request for the removal of her painful skin tag. She has a single, pedunculated, soft, and fleshy papule on her right axilla. She states that the associated pain is exacerbated by tight clothing and walking as she rubs her hand over the skin tag causing disturbance and friction. The pain is relieved by rest and abducting her right hand while at rest, at a standing position or when walking. This is the first time she is seeking medication attention on the same. She has not been prescribed any medication to relieve skin tag-associated pain but she is taking acetaminophen 500 – 1000 mg PO prn for management of headaches. The pain is localized around the area of the skin tag and does not radiate. It is mostly felt (the pain) when the skin tag is disturbed.

Medications: Acetaminophen 500 – 1000 mg PO prn for treatment of headaches.

Allergies:

• Penicillin: rash
• Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Past Medical History: Ms. Jones looks generally healthy; however, she has a history of hypertension and she is obese (body mass index (BMI) – 30.5). Hypertension remains unmanaged. In addition, she takes medications to manage her asthma. But her asthma is well managed (pulse oximetry 99%). She experiences occasion headaches especially when doing an activity or walking. No sputum production, abdominal pain, hemotypsis, orthopnea, paroxysmal nocturnal dyspnea, or uncontrolled shaking or movements.

Sexual/Reproductive History: Heterosexual and sexually active.

Personal/Social History: Denes smoking or illegal drug use. She takes alcohol; average of three bottles per week.

Review of Systems:

OBJECTIVE DATA

Vitals: Heart rate (HR) – 82; respiratory rate (RR) – 16; temperature (F) – 98.9; and blood pressure (BP) 139/87.

Review of Systems:

General: No weight gain or loss.  Appetite is normal. Alert and oriented ×3 (place, person, and time). Appears older that the stated age. Mucous membranes are moist; fair skin turgor. She is well developed and well nourished.

HEENT: Head; normocephalic, atraumatic, and no obvious cuts or wounds. Eyes; NO erythema, no hearing problems, discharge or tinnitus. Eyes; normal visual acuity and accommodation. She does not use eye glasses or contact lenses. Extraocular muscles intact (EOMI). Pupils equal, round, and reactive to light and accommodation (PERRLA).  Nose; no discharge or olfactory function is intact. Throat; no erythema, appears most and pink. No inflammation or pain. No exudates. The tongue protrudes straight.

Neck: no nuchal rigidity, good range of motion, no lymphadenopathy or masses.

Circulatory System: Regular rhythm and rate. S1/S2, S3 and S4 are absent. No gallops, murmurs, or rubs. No jugular venous distention.

Respiratory System: normal to auscultation, normal breathing rate (16 breaths per minute), no chest pain. Slight wheezing and occasional cough that accompanies the wheeze.

Gastrointestinal System: no abnormal bowel movements, no abdominal pain, non-distended, non-tender, no rebound, abdominal sounds present, and no guarding.

Integumentary: Skin tag on her right axillary area. The skin tag is a single, pedunculated, soft, and fleshy papule. No clubbing, cyanosis or edema.

Musculoskeletal System: Normal range of motion is all limbs. No loss of sensation in any limb. No edema.

Central Nervous System: Cranial nerves intact.

Physical Exams Findings: The patient experiences pain when the skin tag is disturbed. The patient rates the pain as 4/10. Weight (kg) – 88, BMI – 30.5.

Laboratory Data: Blood glucose 117mg/dL. Pulse oximetry 99%.

ASSESSEMENT

            Although Ms. Jones medical history is positive for hypertension, headaches, and asthma the patient looks generally healthy. She has a single skin on her right axilla that she has come to the clinic for its removal. She is fully conscious and alert and response to questions in an appropriate manner. The single presenting skin tag has a thin stalk, appears as a benign skin lesion that can be associated with pain if traumatized or irritated.

Differential Diagnoses

1. Acrochordon (skin tag): It can possibly be described as a fibroepithelial polyps, papilloma, or a skin tag (Syed, Lipoff, & Chatterjee, 2020). The rationale is that is presents as a pedunculated, soft, and fleshy papule on the right axilla area. Acrochordons are common skin neoplasms that are mostly associated with obesity. These lesions may be a nuisance to patients. They may be source of nuisance due to associated symptoms such as pain, itching, and rubbing against clothes. Some patients may be disturbed by the appearance of the lesions. They typically arise around the axilla, groin, and neck area (Syed, Lipoff, & Chatterjee, 2020). This is the presumptive final diagnosis due to morphological appearance of the lesion and the fact that the pain feels pain when the lesion is disturbed. Besides, she is obese and this may have contributed to the development of the lesion. Skin tags are also associated with an abnormal lipid profile, type 2 diabetes, cardiovascular disease, and genetic factors (Pandey & Sonthalia, 2021). Syed et al. (2020) that acrochordons are associated with insulin resistance. However, her blood glucose is within the normal range 117mg/dL (before meal: 70 -130 mg/dL); thus, possibility of insulin resistance is minimal or unlikely (SingleCare Team, 2020).
2. Warts: Filiform warts tend to resemble skin tags. The distribution of warts helps to differentiate between acrochordons and warts. Warts are tightly condensed on one area while acrochordons are widely distributed (Syed et al., 2020). Ms. Jones presents with a single soft pediculated fleshy papule; hence, this diagnosis is ruled-out from differential diagnoses.
3. Neurofibroma: It is a benign soft pedunculated growth (Syed et al., 2020). However, the lesion is not well circumscribed in the subcutaneous or dermal tissue. It looks irregular in appearance; hence, it can be ruled-out from the differential diagnosis (Messersmith & Krauland, 2020).
4. Naevi: It is a small pedunculated nevus that often resembles a skin tag. Pigmentation pattern, location, and size of the naevi can differentiate between naevi and acrochordon (Syed et al., 2020). The lesion looks pigmented consistently with the skin and located on the axilla area; thus, this differential diagnosis can be ruled-out.
5. Seborrheic keratosis: Dermatosis papulose nigra appear small, pedunculated, typically pigmented, and/or raised papules that present on the face and associated structures (Syed et al., 2020). Dermatosis papulose nigra is a skin-colored papule or an hyperpigmented papule that develops on the neck and face and developing at adolescence (Xiao, Muse, & Ettefagh, 2020). This differential diagnosis is ruled-out since it presents on the axilla area.

PLAN

• Snip excision: Snipping of the skin tag with a sterilized sharp iris scissor. The method is effective and works immediately. Anesthesia is not necessary (Syed et al., 2020).
• Cryotherapy: Alternatively, the skin tag can be frozen with liquid nitrogen. Liquid nitrogen can be applied directly on the lesion with Cryo-Tweezers. It is less painful (Syed et al., 2020).
• Shave excision: Larger skin tags can be removed with snip excision or a shave after application of local anesthesia (Syed et al., 2020). 
• Follow-up is not necessary (Syed et al., 2020).

Prognosis: A skin tag does not need any intervention unless it disturbs or irritates the patient. It can be removed for cosmetic reasons. The patient should be reassured of the benign nature of the condition (Syed et al., 2020).