{"id":262998,"date":"2023-11-17T18:03:07","date_gmt":"2023-11-17T18:03:07","guid":{"rendered":"https:\/\/nursingstudy.org\/?p=262998"},"modified":"2024-05-09T18:45:58","modified_gmt":"2024-05-09T18:45:58","slug":"comprehensive-soap-note-on-proasis-nursing-paper-example","status":"publish","type":"post","link":"https:\/\/nursingstudy.org\/examples\/comprehensive-soap-note-on-proasis-nursing-paper-example\/","title":{"rendered":"Comprehensive Soap Note on Proasis Nursing Paper Example"},"content":{"rendered":"\n

Comprehensive Soap Note on Proasis Nursing Paper Example<\/strong><\/h2>\n\n\n\n

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.<\/strong><\/p>\n\n\n\n

Patient Initials: ____AZ___ Age: ___43____ Gender: _Female ______<\/p>\n\n\n\n

SUBJECTIVE DATA:<\/strong><\/h3>\n\n\n\n

 Chief Complaint (CC)<\/strong>: \u201cI have red itchy areas on my chest area.\u201d<\/p>\n\n\n\n

History of Present Illness (HPI):\u00a0<\/strong>AZ is a 49-year-old male patient who presents to the clinic with pruritus<\/a>, 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<\/a>.\u00a0 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 on Proasis Nursing Paper Example)<\/p>\n\n\n\n

\"Comprehensive<\/figure>\n\n\n\n

Medications:<\/strong> <\/p>\n\n\n\n

    \n
  1. Cetirizine PO 10mg daily<\/li>\n\n\n\n
  2. Over the counter Tylenol 325mg as needed<\/li>\n\n\n\n
  3. Over the counter Benefiber<\/li>\n<\/ol>\n\n\n\n

    Allergies:<\/strong><\/p>\n\n\n\n

    Sulfa drugs \u2013 rash<\/p>\n\n\n\n

    Histamine<\/p>\n\n\n\n

     Past Medical History (PMH):<\/strong> <\/p>\n\n\n\n

      \n
    1. high blood pressure diagnosed at 41<\/li>\n\n\n\n
    2. Coronary artery disease diagnosed at 43(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/li>\n<\/ol>\n\n\n\n

      Past Surgical History (PSH):<\/strong><\/p>\n\n\n\n

      No surgical history<\/p>\n\n\n\n

       Sexual\/Reproductive History:<\/strong><\/p>\n\n\n\n

      Heterosexual(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Personal\/Social History:<\/strong><\/p>\n\n\n\n

      Immunization History:<\/strong><\/p>\n\n\n\n

      Covid Vaccine #1 4\/3\/2021 #3 \/4 2\/2021 Pfizer<\/p>\n\n\n\n

      Influenza Vaccination 10\/3\/2020<\/p>\n\n\n\n

      PNV 9\/18\/2018<\/p>\n\n\n\n

      Tdap 8\/22\/2017                                                                             <\/p>\n\n\n\n

      Shingles 3\/22\/2016  <\/p>\n\n\n\n

      Significant Family History:<\/strong><\/p>\n\n\n\n

      AZ is married and lives with his wife and 16 year girl.<\/p>\n\n\n\n

      Father died of heart attack aged 71years(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Lifestyle:<\/strong><\/p>\n\n\n\n

      AZ goes for an annual check. He also had a complete blood test three years ago. <\/p>\n\n\n\n

      Review of Systems<\/strong>:<\/p>\n\n\n\n

      General: <\/strong>Well-groomed African American displays a well nutrition status, is cooperative and responds t questions correctly.<\/p>\n\n\n\n

      HEENT: <\/strong>PERRA normocephalic(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Neck: Negative for JVD or bruit, full of ROM, supple..<\/p>\n\n\n\n

      Breasts:<\/strong>. Noncontributory.<\/p>\n\n\n\n

      Respiratory:<\/strong> breathe sounds clear and regular<\/p>\n\n\n\n

      CV:<\/strong> Reports regular heart rate and rhythm, no murmue and negative for peripheral edema.<\/p>\n\n\n\n

      GI:<\/strong>\u00a0 soft non tender.(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      GU:<\/strong>\u00a0denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD\u2019s or HPV. He is sexually active with his longtime girlfriend of 4 years.(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      MS:<\/strong> Full ROM in all extremities.<\/p>\n\n\n\n

      Psych:<\/strong>\u00a0denies history of anxiety or depression<\/a>. No sleep disturbance, delusions or mental health history. He denied suicidal\/homicidal history.\u00a0(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Neuro:<\/strong> A& O *3, DTRS 2+ and symmetric bilaterally<\/p>\n\n\n\n

      Integument\/Heme\/Lymph:<\/strong> No lymph gland swellings, no excessive bleeding<\/p>\n\n\n\n

      Endocrine:<\/strong>\u00a0Negative for polyuria\/polyphagia\/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, No unusual weight gain or loss(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Allergic\/Immunologic:<\/strong> Has sulfa drugs and Histamine allergies.<\/p>\n\n\n\n

       OBJECTIVE DATA<\/strong><\/h3>\n\n\n\n

      Physical Exam:<\/strong><\/p>\n\n\n\n

      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\u20196; BMI 34.45(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      General: A&O x3, appears moderately uncomfortable<\/p>\n\n\n\n

      HEENT: PERRLA, EOMI, or nasopharynx is clear<\/p>\n\n\n\n

      Neck: Carotids no bruit, jvd or no swelling of thyroid gland.<\/p>\n\n\n\n

      Chest\/Lungs: Lungs pos wheezing, pos for scattered rhonchi(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

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

      ABD:  nabs x 4, no organomegaly; mild suprapubic tenderness \u2013 diffuse \u2013 no rebound<\/p>\n\n\n\n

      Genital\/Rectal deferred(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Musculoskeletal: symmetric muscle development \u2013 non contributory<\/p>\n\n\n\n

      Neuro: CN II \u2013 XII grossly intact, DTR\u2019s intact<\/p>\n\n\n\n

      Skin\/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes<\/p>\n\n\n\n

      Diagnostics\/Lab Tests and Results:<\/strong><\/p>\n\n\n\n

      CBC \u2013 WBC 14,500 with + left shift(Comprehensive Soap Note on Proasis Nursing Paper Example)<\/p>\n\n\n\n

      Covid PCR-neg<\/p>\n\n\n\n

      Influenza- neg<\/p>\n\n\n\n

       ASSESSMENT:<\/strong><\/h3>\n\n\n\n

      Differential Diagnosis (DDx):<\/strong><\/p>\n\n\n\n

        \n
      1. Psoriasis confirmed<\/li>\n<\/ol>\n\n\n\n

        According to Kim et al. (2017)- chronic plaque is a hall mark of Psoriasis.<\/p>\n\n\n\n