Posted: September 2nd, 2022

Comprehensive SOAP

Comprehensive SOAP

Patient Initials: __Rodgers Hill_____ Age: __66_____ Gender: __F_____
SUBJECTIVE DATA:
Chief Complaint (CC): The patient came to the clinic complaining of an abnormal skin condition similar to the one presented in figure 3 of the skin conditions. The image is shown below;

History of Present Illness (HPI): Rodgers Hill is a 66-year old Caucasian female. She comes to the facility complaining of an abnormal skin condition involving red plaques around the shoulder and chest area. The condition has persisted for the last one week since onset. The severity has increased gradually for the last three days. The patient indicates she works in an industrial plant but denies she has not experienced a skin condition since she started working in the plant two years ago. She denies any family history of skin conditions or skin cancer. The patient other symptoms such as fever, but complains of feeling unwell.
Medications: Female multivitamin 20mg daily for six months.
Allergies: NKDA
Past Medical History (PMH): The patient with myocardial infarction at age 43 and diabetes at age 45. The two conditions have been well-controlled through medication and lifestyle changes. She was hospitalized for 3 months when she suffered myocardial infarction and one month when she was diagnosed with diabetes. The patient has no childhood illnesses. Not sexually active after the demise of her spouse 10 years ago.
Past Surgical History (PSH): The patient has no surgical illness.
Sexual/Reproductive History: Homosexual and not sexually active. She has not used contraceptives in the past.
Personal/Social History: The patient denies abusing drugs including ETOH or alcohol. She eats three well-balanced meals a day, drinks at least one liter of water, and takes a walk daily.

Immunization History: All immunizations are up-to-date. The latest one is the pneumococcal vaccine which she received in 2018 August at New York-Presbyterian Hospital.
Significant Family History: The patient has no parents after they died 15 years ago due to a heart attack. She has two siblings who are currently in a home for the elderly. One of them has a skin condition called psoriasis. She has two daughters who are married but living in the same state and one son. He has three grandsons who visit her during the holidays.

Lifestyle: The patient is a retired elementary school teacher. She currently lives off her pension. She is supported by her daughters to pay monthly bills. She lives with her son. She takes a walk around the estate daily, watches netball over the weekend and attends a Bible study daily. She visits her siblings at the home for the elderly weekly.
Review of Systems:
General: The patient is alert, stable, and cooperative. She has no weight changes recently. She complains of fatigue and general body weakness. She denies any fever. Her memory is sharp.
HEENT: Hearing and vision of the patient are in good condition. She does not wear eyeglasses or use hearing aids. She took eye examination three months ago. She has no history of eye problems such as glaucoma. She has a good sense of smell and the buccal mucosa is in good condition. The dental condition is healthy as approved by a dental exam 9 months ago. No bleeding gums reported. Chews and swallows food comfortably.
Neck: No plaque involvement on neck or face.
Breasts: No history of tumor, tumor or skin condition.
Respiratory: No breathing problem reported. The patient denies any respiratory problems in the family such as asthma.
Cardiovascular/Peripheral Vascular: The patient suffered myocardial infarction in the past. Reports cardiovascular problems in family history.
Gastrointestinal: Patient denies nausea, reflux, vomiting, diarrhea, and abdominal pains.
Genitourinary: Healthy urinary patterns.
Musculoskeletal: No history of gout or arthritis.
Psychiatric: No history of depression, suicidal thoughts or insomnia.
Neurological: No history of dizziness, seizures, or memory loss.
Skin: The patient reports no skin rashes in the past. Complains of a skin condition for the last one week including reddish plaques. The condition has no discharge. They are not painful, but uncomfortable.
Hematologic: The patient denies any blood disorder.
Endocrine: No endocrine conditions reported.
Allergic/Immunologic: The patient denies any allergic condition.

OBJECTIVE DATA:
Physical Exam:
Vital signs: Oral T 98.4F, Wt 142 lbs, BP 111/71, left arm seated, RR, non-labored, BMI 21.
General: A&O, NAD, dull facial expression. No bad breath. Feeling unwell and uncomfortable. Dressed neatly and good hygiene.
HEENT: Presence of plaque on the skin, scaling around the chest area. Scalp in good condition.
Neck: Carotids no bruit.
Chest/Lungs: CTA AP&L.
Heart/Peripheral Vascular: RRR with minimal murmurs. Pulses +2.
Abdomen: No rebound, benign and mild suprapubic condition.
Genital/Rectal: Deferred.
Musculoskeletal: The patient has symmetric muscle development and 5/5 strength.
Neurological: DTR intact and CN I-IV grossly intact.
Skin: Raised and swollen plaques and reddish areas. No discharge or bleeding.

ASSESSMENT:
Lab Tests: SAO2 – 97%.
Blood test: RF positive
Differential Diagnosis (DDX):
Psoriasis – Psoriasis is a hereditary condition that results in impaired epidermal cells and vascular, biochemical and immunologic abnormalities that are chronic (Watkins, 2016).
Seborrheic dermatitis – It is a scaling disorder that occurs around the neck, scalp, groin, chest, and face. Skin changes due to inflammatory response (Watkins, 2016).
Eczema – Eczema is an immune disorder that is allergic in nature. It begins at a young age. Symptoms fade away as children grow older (Watkins, 2016). It appears in elbows and knees.

Diagnosis: The two conditions including eczema and seborrheic dermatitis are ruled out. Eczema was ruled out since it occurs in elbows and knees. Seborrheic dermatitis was ruled out since it has different symptoms than what the patient had. The possible diagnosis is psoriasis.

Treatment Plan: Applying Clobetasol ointment 0.05% BID 14 days to the affected area. The medication is custom and healthy due to the age factor (Clark, Pope, M & Jaboori, 2015). Reduce stress, use moisturizer and consider light therapy (Goman, 2018). Referrals and X-rays will be made is the condition persists after 14 days.

Health Promotion: Eat healthy balanced diet meals including fish, oats, avocado, nuts, and oranges. The fruits such as avocado and walnuts have healthy fats essential for repair of skin (Goman, 2018). Maintain hygiene and avoid irritants.

Disease Prevention: Avoid dietary and environmental changes. Drink plenty of water to avoid the accumulation of contaminants. Keep off chemical irritants since they can affect the skin. Eat healthy meals to boost immunity (Artandi & Stewart, 2018). Consider immunization at a health facility.

REFLECTION: The experience of examining the patient was transforming since it indicated the need for a comprehensive and objective examination. I have also learned how to keep a patient calm during the physical examination. It is also important to apply preventive approaches to improve health promotion in the society. In the future, I will collect more details about the history of a patient by accessing their medical files or asking questions. I agree with the preceptor based on the evidence presented during the examination.

References
Artandi, M. K., & Stewart, R. W. (2018). The Outpatient Physical Examination. Medical Clinics, 102(3), 465-473.
Clark, G. W., Pope, S. M., & Jaboori, K. A. (2015). Diagnosis and treatment of seborrheic dermatitis. American Family Physician, 91(3).
Goman, T. (2018). Scalp psoriasis: management and treatment. Journal of Community Nursing, 32(1).
Watkins, J. (2016). Management of eczema and psoriasis in the community. British Journal of Community Nursing, 21(6), 274-279.

Order | Check Discount

Tags: Comprehensive SOAP