Posted: March 28th, 2023

Patient Initials: R.H. Age: 66 Gender: Female

Comprehensive SOAP Note:

Comprehensive SOAP

Patient Initials: R.H. Age: 66 Gender: Female

SUBJECTIVE DATA:
Chief Complaint (CC): The patient presents with an abnormal skin condition on her shoulder and chest, resembling the red plaques in Figure 3 of the skin conditions.

History of Present Illness (HPI): R.H. is a 66-year-old Caucasian female who reports an abnormal skin condition characterized by red plaques on her shoulder and chest area. The condition has been present for one week and has gradually worsened in the last three days. She reports feeling unwell, but denies experiencing fever or other symptoms. R.H. works in an industrial plant but denies any previous skin conditions. She denies a family history of skin conditions or skin cancer.

Medications: Female multivitamin 20mg daily for six months.

Allergies: NKDA

Past Medical History (PMH): R.H. has a history of myocardial infarction at age 43 and diabetes at age 45, both well-controlled through medication and lifestyle changes. She has no childhood illnesses and is not sexually active since the death of her spouse 10 years ago.

Past Surgical History (PSH): No surgical history.

Sexual/Reproductive History: Homosexual and not sexually active. She has not used contraceptives in the past.

Personal/Social History: R.H. is a retired elementary school teacher, living with her son, and supported financially by her daughters. She maintains a healthy lifestyle with three well-balanced meals a day, daily walks, and attends a Bible study. She denies drug or alcohol abuse.

Immunization History: All immunizations are up-to-date, including the pneumococcal vaccine received in 2018 at New York-Presbyterian Hospital.

Significant Family History: R.H.’s parents passed away 15 years ago due to a heart attack. She has two siblings in a home for the elderly, one of whom has psoriasis. She has two married daughters and one son with three grandsons who visit her during the holidays.

Review of Systems:
General: The patient appears alert and cooperative with no recent weight changes. Reports fatigue and general body weakness but denies fever. Memory is sharp.

HEENT: Hearing and vision are normal, with no history of eye problems such as glaucoma. Buccal mucosa is in good condition, and dental examination 9 months ago confirmed healthy dental status.

Neck: No plaque involvement on neck or face.

Breasts: No history of tumor, tumor or skin condition.

Respiratory: No respiratory problems reported, and denies a family history of asthma.

Cardiovascular/Peripheral Vascular: R.H. has a history of myocardial infarction, and reports cardiovascular problems in family history.

Gastrointestinal: No nausea, reflux, vomiting, diarrhea, or abdominal pain reported.

Genitourinary: Healthy urinary patterns reported.

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 prior skin rashes but has experienced reddish plaques for the last week. The condition is uncomfortable but not painful, with no discharge.

Hematologic: The patient denies any blood disorders.

Endocrine: No endocrine conditions reported.

Allergic/Immunologic: The patient denies any allergic conditions.

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.

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Tags: Comprehensive SOAP Note, Patient Initials: R.H. Age: 66 Gender: Female