NURS6512 SKin Assessment SOAP Note
Select one pores and skin situation graphic (establish by quantity in your Chief Criticism) to doc your task within the SOAP (Subjective, Goal, Assessment, and Plan) be aware format, moderately than the standard narrative fashion. Seek advice from Chapter 2 of the Sullivan textual content and the Complete SOAP Template on this week’s Studying Sources for steering. Keep in mind that not all complete SOAP knowledge are included in each affected person case.
Use scientific terminologies to elucidate the bodily traits featured within the graphic. Formulate a differential analysis of three to 5 doable circumstances for the pores and skin graphic that you simply selected. Decide which is almost certainly to be the proper analysis and clarify your reasoning utilizing no less than three completely different references from present proof primarily based literature. NURS6512 SKin Assessment SOAP Note
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Complete SOAP
Affected person Initials: __JJ_____ Age: __54_____ Gender: __M_____
SUBJECTIVE DATA:
Chief Criticism (CC): Small, itchy, raised patches on decrease again
Historical past of Current Sickness (HPI): Jeremiah Jergens is a 54-year-old Caucasian male who presents at the moment with a big cluster of thick, purple, raised patches on his decrease again. Jeremiah first seen the patches four years in the past, a number of days after he recovered from a strep throat an infection. He has related signs of tenderness, itchiness and flaking of the patches. They typically bleed when he accidently scratches off a patch. He reported the he’s “embarrassed by the look of it” and won’t take his shirt off on the seashore. He has additionally seen each his knees, joints in his fingers and again are very stiff within the mornings however lessens after strolling and utilizing his joints for a bit. He has been utilizing Tylenol to Help with the joint ache and for the patches, he stories utilizing Benadryl ointment for the itching. Each present minimal aid. He charges his discomfort a four/10 at the moment however in mornings 7/10 because of the joint ache. Jeremiah Jergens, a 54-year-old Caucasian male, seems at the moment with a number of thick, purple, elevated patches on his decrease again. He has had these lesions for a while. 4 years in the past, when Jeremiah had recovered from strep throat, he seen the spots. The spots are delicate, itchy, and flaky, and he has different signs as properly. He steadily scratches off patches, inflicting them to bleed. As he put it, he’s “embarrassed by the look of it,” therefore he is not going to go shirtless on the seashore. He additionally experiences morning stiffness in his knees, fingers, and again, which he says progressively improves after some bodily exercise. He says he has been relieving his joint discomfort with Tylenol and his patch itching with Benadryl cream. Each are solely mildly useful. Since waking up, his joint ache has elevated from a four to a 7 on his ache scale.
Medicines:
Over-the-counter Tylenol 500mg PO as soon as day by day within the morning
Over-the-counter Benadryl Additional Power topical ointment as wanted
Atenolol 75 mg PO twice day by day
Over-the-counter Aspirin 325 mg PO as soon as day by day
Males’s Multivitamin as soon as day by day
Epi-Pen as wanted
CONT …
Complete SOAP Template – NURS6512 SKin Assessment SOAP Note
Affected person Initials: ZY Age: 65 Gender: Feminine
SUBJECTIVE DATA:
“I’ve a number of purple raised lesions throughout my chest and abdomen”. This occurred about two weeks in the past
Chief Criticism (CC): A number of raised purple spots throughout torso (picture #2).
Historical past of Current Sickness (HPI): A 65-year-old Caucasian male presents to the clinic with a number of purple papule throughout torso. The spots are purple in shade, some raised and a few are flat to the pores and skin. There are about 48 spots they usually seem like little cherries and have tough and clean edges to it. It began about two weeks in the past with 5 spots and progressively elevated to about 48 spots. There aren’t any relieving or aggravating elements.
You have to embody the 7 attributes of every principal symptom:
