Soap Note
| Name: F.Z | Date: 14th Sept, 2020 | Time: 1600hrs |
| Age: 68 years old | Sex: M | |
| SUBJECTIVE | ||
| CC: Itchy skin lesions | ||
| HPI: A male patient who present to the facility with itchy skin lesions that has been present for few months. According to him, he noticed the lesions on his knees and is now extending to his elbows and scalp. He reports that the lesions are slightly itchy and this has been the case for the last three weeks. She is stressful since the affected areas are now becoming painful. He has tried to change the bathing soap with no change and has been using ibuprofen 400mg three time a day for the relief of pain. According to him, the severity is 7/10.
|
||
| Medications: OTC Ibuprofen 400 mg PO every 6 hours and Ortho Tri-cyclin 1 tablet PO daily
|
||
| PMH
Allergies: NKDA
Medication Intolerances: No history of any medication intolerance
Chronic Illnesses/Major traumas: No history of the chronic or major traumas reported
Hospitalizations/Surgeries: No history of hospitalization for HTN, diabetes, asthma, peptic ulcers, lung illness, heart disease, Tuberculosis, kidney problem or the thyroid issues
|
||
| Family History: Mother is alive and diagnosed with diabetes. Father dead with no known cause of the death. Maternal grandfather, dead, diagnosed with psoriasis | ||
| Social History: he is an undergraduate and a retired teacher. Like working in the farm. Reports no history of substance or alcohol use. Lives with the wife and three grandchildren. Stable and can perform his ADLs independently. |
| ROS | |
| General: No reported chills or fever, no changes in the weight, report no night sweats, and denies fatigue. | Cardiovascular: Denies palpitations, pain of the chest, PND, orthopnea, and edema. |
| Skin: Delayed healing, bruises, discoloration of the skin, and presence of the moles and lesions | Respiratory: Denies coughing, wheezes, dyspnea, and history of pneumonia, tuberculosis, and hemoptysis. |
| Eyes: Denies the use of the corrective lenses, blurs, changes in the vision | Gastrointestinal: Denies abdominal pain, N/V/D, constipation, ulcers, black tarry stools, eating disorders, hepatitis, and the hemorrhoids. |
| Ears: Denies ear discharges, paining ear, hearing loss, and the ringing of the ear. | Genitourinary/Gynecological: Denies changes in the frequency, urgency, and the changes in the urine color. No urinary complaints |
| Nose/Mouth/Throat: denies sinus issues, dysphagia, bleeding or discharge of the nose, dental illness, hoarseness, and the pain of the throat.
|
Musculoskeletal: no history of the fracture, denies stiffness, back pain. Confirms pain and swelling of the knee and elbow.
|
| Breast; Denies bumps, lumps and any changes | Neurological: Denies syncope, seizures, transient paralysis, paresthesia, and the spells of the black out. Confirms the weakness in the knee and elbow of the right hand. |
| Heme/Lymph/Endo: He is HIV negative, have bruises, no history of blood transfusion. Denies night sweats, increase in the hunger, heat or cold tolerance. | Psychiatric: Denies depression, suicidal thoughts, sleeping difficulties, and anxiety. |
| OBJECTIVE |
| Weight 63 kg BMI 21.9 | Temp 97 F | BP 120/68 |
| Height 170 cm | Pulse 70 | Resp 16 |
| General Appearance: the patient looks health and oriented ×4. He is in no acute distress and responding to question appropriately. . | ||
| Skin: rashes and lesion noted. Skin is not intact | ||
| HEENT: Head: normocephalic, atraumatic, with no lesions. Evenly distributed hair. Eyes: PERRLA and intact EOMs. No scleral injection or conjunctival. Ears: there is patent canals, bilateral TMS which is pearly grey with no positive light reflex. The landmarks are easily visualized. Nose: pinkish norsal mucosa with normal turbinates, no septal deviation. Neck: supple, full ROM, no cervical lymphadenopathy, no occipital nodes, no thyromegaly or nodules. There is pinkish and moist oral mucosa. The pharynx is non-erythematous without exudate. The teeth are in good repair.
|
||
| Cardiovascular: There is regular rate and rhythm in S1, S2. No production of extra sounds, no clicks, no rubs, nor murmur. There is 3+ throughout with no edema. | ||
| Respiratory: there is regular and easy respirations, the lungs is clear to auscultation bilaterally. There is symmetric chest wall. | ||
| Gastrointestinal: no abdomen obese, active BS in all the 4 quadrants, soft and non-tender abdomen. No hepatosplenomegally. | ||
| Breast: no masses or tenderness upon palpitation. No discharge, no dimple, no wrinkle. There is no discoloration of the skin | ||
| Genitourinary: non-distended bladder, no CVA tenderness. There is normal distribution of the pubic hair. Skin consistent with general pigmentation. No vulvar lesion noted and both testes palpable, no masses and lesions, no hernia, no urethral discharge (Kim, et al., 2018). | ||
| Musculoskeletal: Full ROM noted in all the 4 extremities upon examinations | ||
| Neurological: there is clear speech, good tone, stable, and normal gait. | ||
| Psychiatric: Alert and oriented. × 4, maintaining the eye contact, soft speech, clear and normal rate and codence. Responding to the questions appropriately. | ||
| Lab Tests
Complete Blood Count: the cause of the itching skin can be due to the iron deficiency Chest-X-rays: this help in revealing about the presence of the enlarged lymph nodes which is also characterized with itchy skin. Skin Biopsy: reveal the cause of the growth, sore, and rash (Habif, 2016).
|
||
| Special Tests: skin culture to determine the microorganism that affect the skin
|
||
| Diagnosis | ||
| Differential Diagnoses
1- Squamous cell carcinoma 2- Benign skin lesions 3- Actinic keratosis Diagnosis o Basal cell carcinoma
|
||
| Plan/Therapeutics | ||
| o Plan:
· Further testing: skin culture to determine the microorganism causing the skin disease. Performance of the histology to confirm the nodular basal cell carcinoma · Medication: prescription creams, topical anti-tumor medication and chemotherapy, photodynamic therapy, and the electrosurgery and the wide local excision · Education: patient educated to avoid potentiating factors for example the sun exposure, arsenic ingestion, tanning beds, and the ionizing radiation · Non-medication treatments: cryotherapy, curettage and electrodesiccation, laser surgery, and the radiation therapy (Ely et al., 2014).
|
||
| Evaluation of patient encounter: the patient is alert and well-oriented but is concerned about his condition that makes him uncomfortable. She is not aware of the condition and the type of medication to be used or how to prevent the exposure to risk of worsening his condition. The patient requires proper education and medication. |
Needs help with similar assignment?
We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper
Get Answer Over WhatsApp
Order Paper Now
