SOAP vocabulary

Question 1

Mycotic nail description

Answer 1

• • discolored distally, elongated, thick, hypertrophic, crumbly, discolored, deformed, ridged, malodorous, lysing with friable subungual debris which after debridement to underlying nail bed reveals a characteristic fungal/yeast/mold odor and consistency

Question 2

callus CC

Answer 2

• Patient presents today for a follow-up of a recurrent and chronic callus formation between
• with a complaint of a [new onset, chronic, tender, painful] callus formation beneath the [first, second, third, fourth, fifth] [right, left] metatarsal head with pain/no pain upon [standing, walking, exercise, performing work duties, barefoot walking, closed-toe shoe gear, and even when off weight-bearing].
• The condition has been present for [days, weeks, months, years] and recently is [worsened, the same, improved].
• She has attempted [self-debridement, soaks, lotions, OTC padding, shoe gear changes] which [have, have not] provided relief
• She [admits, denies] any r
  recent trauma or inciting events
• She [has, has not] noted any drainage or bleeding from the area

Question 3

Objective of CC

Answer 3

• There [is, is not] pain on palpation of the [1st, 2nd, 3rd, 4th] webspace of the [right, left] foot where a hyperkeratotic lesion is evident

Question 4

Lesion description

Answer 4

surface is described as [pigmented black, pigmented brown, pigmented blue, homogenous in color, heterogeneous in color].
The surface is [flat, nodular, raised, waxy].
The texture is [dry, inflamed, moist, peeling, scaling, supple, ulcerated].
Measures [1,2,3,4,5,6,7,8,9,10] [mm, cm, inches]
long by [1 , 2, 3, 4, 5, 6, 7, 8, 9, 10] [mm, cm, inches] wide.
The borders are described as [regular, irregular, not well defined, well defined, serpintiginous, rolled, hyperkeratotic]. [hotspots].
Acronym: colour, surface, Texture, measures, borders,
CSTMB

Question 4

Lesion description

Answer 4

surface is described as [pigmented black, pigmented brown, pigmented blue, homogenous in color, heterogeneous in color].
The surface is [flat, nodular, raised, waxy].
The texture is [dry, inflamed, moist, peeling, scaling, supple, ulcerated].
Measures [1,2,3,4,5,6,7,8,9,10] [mm, cm, inches]
long by [1 , 2, 3, 4, 5, 6, 7, 8, 9, 10] [mm, cm, inches] wide.
The borders are described as [regular, irregular, not well defined, well defined, serpintiginous, rolled, hyperkeratotic]. [hotspots].
Acronym: colour, surface, Texture, measures, borders,
CSTMB