Find attached SOAP NOTE on Striae Gravidarum
Below is an example to follow :
Thanks
Comprehensive SOAP Exemplar
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: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 daily
4.) Singulair 10mg daily
5.) Over the counter Tylenol 325mg as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.
He has a primary care nurse practiti
The skin condition chosen is “ striae gravidarum”
Use clinical terminologies to explain the physical characteristics of “ Striae gravidarum” Formulate a differential diagnosis of three to five possible conditions for striae gravidarum”. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
· Ball: Seidel’s Guide to Physical Examination, 8th Edition
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Below is the template to follow :
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
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