Posted: September 2nd, 2022

Comprehensive SOAP

Comprehensive SOAP

Affected person Initials: __Rodgers Hill_____ Age: __66_____ Gender: __F_____
SUBJECTIVE DATA:
Chief Grievance (CC): The affected person got here to the clinic complaining of an irregular pores and skin situation much like the one offered in determine three of the pores and skin situations. The picture is proven under;

Historical past of Current Sickness (HPI): Rodgers Hill is a 66-year outdated Caucasian feminine. She involves the power complaining of an irregular pores and skin situation involving pink plaques across the shoulder and chest space. The situation has persevered for the final one week since onset. The severity has elevated progressively for the final three days. The affected person signifies she works in an industrial plant however denies she has not skilled a pores and skin situation since she began working within the plant two years in the past. She denies any household historical past of pores and skin situations or pores and skin most cancers. The affected person different signs comparable to fever, however complains of feeling unwell.
Medicines: Feminine multivitamin 20mg each day for six months.
Allergic reactions: NKDA
Previous Medical Historical past (PMH): The affected person with myocardial infarction at age 43 and diabetes at age 45. The 2 situations have been well-controlled by means of medicine and life-style modifications. She was hospitalized for three months when she suffered myocardial infarction and one month when she was identified with diabetes. The affected person has no childhood sicknesses. Not sexually lively after the demise of her partner 10 years in the past.
Previous Surgical Historical past (PSH): The affected person has no surgical sickness.
Sexual/Reproductive Historical past: Gay and never sexually lively. She has not used contraceptives up to now.
Private/Social Historical past: The affected person denies abusing medication together with ETOH or alcohol. She eats three well-balanced meals a day, drinks not less than one liter of water, and takes a stroll each day.

Immunization Historical past: All immunizations are up-to-date. The most recent one is the pneumococcal vaccine which she acquired in 2018 August at New York-Presbyterian Hospital.
Vital Household Historical past: The affected person has no dad and mom after they died 15 years in the past resulting from a coronary heart assault. She has two siblings who’re presently in a house for the aged. One in every of them has a pores and skin situation referred to as psoriasis. She has two daughters who’re married however residing in the identical state and one son. He has three grandsons who go to her in the course of the holidays.

Life-style: The affected person is a retired elementary faculty instructor. She presently lives off her pension. She is supported by her daughters to pay month-to-month payments. She lives along with her son. She takes a stroll across the property each day, watches netball over the weekend and attends a Bible research each day. She visits her siblings on the residence for the aged weekly.
Assessment of Methods:
Common: The affected person is alert, steady, and cooperative. She has no weight modifications lately. She complains of fatigue and normal physique weak point. She denies any fever. Her reminiscence is sharp.
HEENT: Listening to and imaginative and prescient of the affected person are in good situation. She doesn’t put on eyeglasses or use listening to aids. She took eye examination three months in the past. She has no historical past of eye issues comparable to glaucoma. She has an excellent sense of odor and the buccal mucosa is in good situation. The dental situation is wholesome as accepted by a dental examination 9 months in the past. No bleeding gums reported. Chews and swallows meals comfortably.
Neck: No plaque involvement on neck or face.
Breasts: No historical past of tumor, tumor or pores and skin situation.
Respiratory: No respiration drawback reported. The affected person denies any respiratory issues within the household comparable to bronchial asthma.
Cardiovascular/Peripheral Vascular: The affected person suffered myocardial infarction up to now. Stories cardiovascular issues in household historical past.
Gastrointestinal: Affected person denies nausea, reflux, vomiting, diarrhea, and stomach pains.
Genitourinary: Wholesome urinary patterns.
Musculoskeletal: No historical past of gout or arthritis.
Psychiatric: No historical past of melancholy, suicidal ideas or insomnia.
Neurological: No historical past of dizziness, seizures, or reminiscence loss.
Pores and skin: The affected person reviews no pores and skin rashes up to now. Complains of a pores and skin situation for the final one week together with reddish plaques. The situation has no discharge. They don’t seem to be painful, however uncomfortable.
Hematologic: The affected person denies any blood dysfunction.
Endocrine: No endocrine situations reported.
Allergic/Immunologic: The affected person denies any allergic situation.

OBJECTIVE DATA:
Bodily Examination:
Important indicators: Oral T 98.4F, Wt 142 lbs, BP 111/71, left arm seated, RR, non-labored, BMI 21.
Common: A&O, NAD, boring facial features. No unhealthy breath. Feeling unwell and uncomfortable. Dressed neatly and good hygiene.
HEENT: Presence of plaque on the pores and skin, scaling across the chest space. Scalp in good situation.
Neck: Carotids no bruit.
Chest/Lungs: CTA AP&L.
Coronary heart/Peripheral Vascular: RRR with minimal murmurs. Pulses +2.
Stomach: No rebound, benign and delicate suprapubic situation.
Genital/Rectal: Deferred.
Musculoskeletal: The affected person has symmetric muscle improvement and 5/5 power.
Neurological: DTR intact and CN I-IV grossly intact.
Pores and skin: Raised and swollen plaques and reddish areas. No discharge or bleeding.

ASSESSMENT:
Lab Checks: SAO2 – 97%.
Blood take a look at: RF optimistic
Differential Prognosis (DDX):
Psoriasis – Psoriasis is a hereditary situation that ends in impaired epidermal cells and vascular, biochemical and immunologic abnormalities which are power (Watkins, 2016).
Seborrheic dermatitis – It’s a scaling dysfunction that happens across the neck, scalp, groin, chest, and face. Pores and skin modifications resulting from inflammatory response (Watkins, 2016).
Eczema – Eczema is an immune dysfunction that’s allergic in nature. It begins at a younger age. Signs fade away as kids get older (Watkins, 2016). It seems in elbows and knees.

Prognosis: The 2 situations together with eczema and seborrheic dermatitis are dominated out. Eczema was dominated out because it happens in elbows and knees. Seborrheic dermatitis was dominated out because it has completely different signs than what the affected person had. The doable prognosis is psoriasis.

Remedy Plan: Making use of Clobetasol ointment zero.05% BID 14 days to the affected space. The medicine is customized and wholesome as a result of age issue (Clark, Pope, M & Jaboori, 2015). Cut back stress, use moisturizer and contemplate gentle remedy (Goman, 2018). Referrals and X-rays will likely be made is the situation persists after 14 days.

Well being Promotion: Eat wholesome balanced weight-reduction plan meals together with fish, oats, avocado, nuts, and oranges. The fruits comparable to avocado and walnuts have wholesome fat important for restore of pores and skin (Goman, 2018). Preserve hygiene and keep away from irritants.

Illness Prevention: Keep away from dietary and environmental modifications. Drink loads of water to keep away from the buildup of contaminants. Maintain off chemical irritants since they will have an effect on the pores and skin. Eat wholesome meals to spice up immunity (Artandi & Stewart, 2018). Take into account immunization at a well being facility.

REFLECTION: The expertise of analyzing the affected person was remodeling because it indicated the necessity for a complete and goal examination. I’ve additionally discovered find out how to maintain a affected person calm in the course of the bodily examination. It’s also necessary to use preventive approaches to enhance well being promotion within the society. Sooner or later, I’ll acquire extra particulars concerning the historical past of a affected person by accessing their medical recordsdata or asking questions. I agree with the preceptor based mostly on the proof offered in the course of the examination.

References
Artandi, M. Okay., & Stewart, R. W. (2018). The Outpatient Bodily Examination. Medical Clinics, 102(three), 465-473.
Clark, G. W., Pope, S. M., & Jaboori, Okay. A. (2015). Prognosis and remedy of seborrheic dermatitis. American Household Doctor, 91(three).
Goman, T. (2018). Scalp psoriasis: administration and remedy. Journal of Group Nursing, 32(1).
Watkins, J. (2016). Administration of eczema and psoriasis locally. British Journal of Group Nursing, 21(6), 274-279.

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