Comprehensive Soap Note Nursing Essay Example

Comprehensive Soap Note Nursing Essay Example

Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

Patient Initials: ____AZ___ Age: ___43____ Gender: _Female ______

SUBJECTIVE DATA:

 Chief Complaint (CC): “I have red itchy areas on my chest area.”

History of Present Illness (HPI): AZ is a 49-year-old male patient who presents to the clinic with pruritus, red patches secondary to pruritus, dry scaling plaques around the chest and neck area. The patient reports the patch started out smaller a few months ago and has witnessed the patch progressively grow in size.  He report the itchiness aggravates sometimes but denies any pain or associated symptoms. He reports having applied an over the counter lotion to the area affected with no symptoms relief.(Comprehensive Soap Note Nursing Essay Example)

Medications: 

1. Cetirizine PO 10mg daily
2. Over the counter Tylenol 325mg as needed
3. Over the counter Benefiber

Allergies:

Sulfa drugs – rash

Histamine

 Past Medical History (PMH): 

1. high blood pressure diagnosed at 41
2. Coronary artery disease diagnosed at 43

Past Surgical History (PSH):

No surgical history

 Sexual/Reproductive History:

Heterosexual

Personal/Social History:

Immunization History:

Covid Vaccine #1 4/3/2021 #3 /4 2/2021 Pfizer

Influenza Vaccination 10/3/2020

PNV 9/18/2018

Tdap 8/22/2017                                                                             

Shingles 3/22/2016  

Significant Family History:

AZ is married and lives with his wife and 16 year girl.

Father died of heart attack aged 71years

Lifestyle:

AZ goes for an annual check. He also had a complete blood test three years ago. 

Review of Systems:

General: Well-groomed African American displays a well nutrition status, is cooperative and responds t questions correctly.

HEENT: PERRA normocephalic

Neck: Negative for JVD or bruit, full of ROM, supple..

Breasts:. Noncontributory.(Comprehensive Soap Note Nursing Essay Example)

Respiratory: breathe sounds clear and regular

CV: Reports regular heart rate and rhythm, no murmue and negative for peripheral edema.

GI:  soft non tender.

GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his longtime girlfriend of 4 years.

MS: Full ROM in all extremities.

Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history. (Comprehensive Soap Note Nursing Essay Example)

Neuro: A& O *3, DTRS 2+ and symmetric bilaterally

Integument/Heme/Lymph: No lymph gland swellings, no excessive bleeding

Endocrine: Negative for polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, No unusual weight gain or loss

Allergic/Immunologic: Has sulfa drugs and Histamine allergies.

 OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 143/99, left arm, sitting, regular cuff; P 91 and regular; T 99.9 Orally; RR 17; non-labored; Wt: 220 lbs; Ht: 5’6; BMI 34.45

General: A&O x3, appears moderately uncomfortable

HEENT: PERRLA, EOMI, or nasopharynx is clear(Comprehensive Soap Note Nursing Essay Example)

Neck: Carotids no bruit, jvd or no swelling of thyroid gland.

Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD:  nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal deferred

Musculoskeletal: symmetric muscle development – non contributory

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

Diagnostics/Lab Tests and Results:

CBC – WBC 14,500 with + left shift

Covid PCR-neg(Comprehensive Soap Note Nursing Essay Example)

Influenza- neg

 ASSESSMENT:

Differential Diagnosis (DDx):

1. Psoriasis confirmed

According to Kim et al. (2017)- chronic plaque is a hall mark of Psoriasis.

• Contact dermatitis (refuted) -Ruled out because it manifests with patches or plaques with angular corners and geometric outlines (Griffiths et al., 2017).(Comprehensive Soap Note Nursing Essay Example)
• Atopic dermatitis 9 (refuted)- Ruled out because its predominant symptom is pruritus and typical morphology (Claben et al., 2019).

Primary Diagnoses:

Psorais – the patient had the symptoms and risk factors like smoking and taking alcohol.

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

References

Claßen, A., Buhl, T., Schubert, S., Worm, M., Bauer, A., Geier, J., … & Information Network of Departments of Dermatology (IVDK) study group. (2019). Allergic contact dermatitis in psoriasis. British Journal of Dermatology, 180(2), e47-e47.(Comprehensive Soap Note Nursing Essay Example)

Griffiths, C. E., van de Kerkhof, P., & Czarnecka-Operacz, M. (2017). Psoriasis and atopic dermatitis. Dermatology and therapy, 7(1), 31-41.(Comprehensive Soap Note Nursing Essay Example)

Kim, W. B., Jerome, D., & Yeung, J. (2017). Diagnosis and management of psoriasis. Canadian Family Physician, 63(4), 278-285.

https://www.ncbi.nlm.nih.gov/