NURS6512 SKin Assessment SOAP Note
Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature. NURS6512 SKin Assessment SOAP Note
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Comprehensive SOAP
Patient Initials: __JJ_____ Age: __54_____ Gender: __M_____
SUBJECTIVE DATA:
Chief Complaint (CC): Small, itchy, raised patches on lower back
History of Present Illness (HPI): Jeremiah Jergens is a 54-year-old Caucasian male who presents today with a large cluster of thick, red, raised patches on his lower back. Jeremiah first noticed the patches 4 years ago, a few days after he recovered from a strep throat infection. He has associated symptoms of tenderness, itchiness and flaking of the patches. They often bleed when he accidently scratches off a patch. He reported the he is “embarrassed by the look of it” and will not take his shirt off at the beach. He has also noticed both his knees, joints in his fingers and back are very stiff in the mornings but lessens after walking and using his joints for a bit. He has been using Tylenol to help with the joint pain and for the patches, he reports using Benadryl ointment for the itching. Both provide minimal relief. He rates his discomfort a 4/10 today but in mornings 7/10 due to the joint pain. Jeremiah Jergens, a 54-year-old Caucasian male, appears today with multiple thick, red, elevated patches on his lower back. He has had these lesions for some time. Four years ago, when Jeremiah had recovered from strep throat, he noticed the spots. The spots are sensitive, itchy, and flaky, and he has other symptoms as well. He frequently scratches off patches, causing them to bleed. As he put it, he is “embarrassed by the look of it,” hence he will not go shirtless on the beach. He also experiences morning stiffness in his knees, fingers, and back, which he says gradually improves after some physical activity. He says he has been relieving his joint discomfort with Tylenol and his patch itching with Benadryl cream. Both are only mildly helpful. Since waking up, his joint pain has increased from a 4 to a 7 on his pain scale.
Medications:
Over-the-counter Tylenol 500mg PO once daily in the morning
Over-the-counter Benadryl Extra Strength topical ointment as needed
Atenolol 75 mg PO twice daily
Over-the-counter Aspirin 325 mg PO once daily
Men’s Multivitamin once daily
Epi-Pen as needed
CONT …
Comprehensive SOAP Template – NURS6512 SKin Assessment SOAP Note
Patient Initials: ZY Age: 65 Gender: Female
SUBJECTIVE DATA:
“I have multiple red raised lesions all over my chest and stomach”. This happened about two weeks ago
Chief Complaint (CC): Multiple raised red spots all over torso (image #2).
History of Present Illness (HPI): A 65-year-old Caucasian male presents to the clinic with multiple red papule all over torso. The spots are red in color, some raised and some are flat to the skin. There are about 48 spots and they look like little cherries and have rough and smooth edges to it. It started about two weeks ago with 5 spots and gradually increased to about 48 spots. There are no relieving or aggravating factors.
You must include the 7 attributes of each principal symptom:
