This article provides a solved sample of Comprehensive SOAP.
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Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week\’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Use medical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. 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
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.…
Solution
Comprehensive SOAP
Patient Initials: ABC Age: 57 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): Painful blistering rash limited on a stripe-like area of the arm
History of Present Illness (HPI): ABC is a 57-year-old female of Cuban Hispanic origin. The patient presented at the clinic with complaint of a Painful rash limited on a stripe-like area of the arm. She believes she has had it for the last 4 days. She complains of pain and discomfort when using the right arm to do any home chores. She has had shingles in twice in the past 5 years and notes that it feels the same as in the past. She has been taking 2 tablets of Tylenol every 6 hours to manage the pain. ABC rates her pain as an 8 out of 10 on the pain scale 0-10.
Medications:
- Aspirin 81 mg daily
- Lipitor 20 mg daily
- Hydrochlorothiazide 50 mg daily
- Atenolol 100 mg daily
- Diovan 80 mg daily,
Allergies: Has no known drug allergy, no seasonal or environmental allergies
Past Medical History (PMH):
- Hypertension for two years
- Hyperlipidemia controlled by Simistatin
- Obesity
- chronic obstructive pulmonary disease- quiet
- mild pulmonary hypertension
Past Surgical History (PSH):
Minor surgery to remove atypical moles for melanocytic nevi from her left-hand fingers 3 years ago (Colyar, 2015)
Sexual/Reproductive History: If applicable,
Heterosexual
Non-menstruating
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Personal/Social History:
Adopted light exercises and is on a diet for the last 4 months
Immunization History:
Flu- Has not received for this flu season.
Pneumovax-Unknown
Tetanus/Pertussis- Unsure of her last vaccination.
Significant Family History: Family history of Hypertension, Obesity and diabetes
Lifestyle: Lives with husband and youngest daughter. Close family lives nearby, has a support system. She owns her home, and receives pension. Financially independent,
Has taken up walking and jogging for the last 6 months, slight changes in diet, support from family members play a key role.
Review of Systems:
General: + fatigue and fevers for 4 days, slight weight loss, poor sleep since illness started.
CARDIOVASCULAR/PERIPHERAL VASCULAR: SOB, Fatigue w/e exertion, Date of ECG/ Cardiac work up is 8 months ago.
Breasts: No history of abnormal mammograms, no breast changes, no history of rashes, or lesions in the breast area
GI: No abdominal pain, no nausea or vomiting, no diarrhea, no constipation, no melena, no hematochezia, no hemorrhoids and no indigestion.
GU: Slight stress Incontinence, No history of STD’s or HPV, heterosexual, and sexually active
MS: No myalgia, no arthritis, She complains of slight weakness
Psych: no history of anxiety or depression, no suicidal or homicidal history
Neuro: no headaches or imbalance. No change in memory or thinking patterns; no twitches or abnormal movements, No falls or seizure history.
HEME: rashes on right arm, no radiation of rash at this time, no itching, no acne, history of moles on left fingers, no hair loss, no history of skin cancer. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endo: No endocrine symptoms or hormone therapies
Allergic/ Immunologic: Has no known immune deficiencies, Last HIV test was 3 years ago.
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OBJECTIVE DATA:
Physical Exam:
Vital signs: Vital Signs: Pulse 83 and regular Temp. 99F Resp. B/P 1st 120/72
Pulse Ox 98%, T 98.3 Orally; RR 16; non-labored; Wt: 165 lbs; Ht: 5’3; BMI 29.5
General: NAD, well-groomed
HEENT: No changes in vision or hearing. No history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She has had no recent ear infections, drainage or pain.
She does have a history recent sinus infection. She denies loss of taste, no difficulty in chewing and no swallowing and tooth/ gum pain or bleeding.
Neck: No pain on the neck, no injury or history of disc disease
Chest/Lungs: No chest pain
Heart/Peripheral Vascular: SOB, S1 and S2 audible, no murmur, gallops, heaves, or thrills. PMI at 4-5th ICS, MCL.
Abdomen: Bowel sounds present in all four quadrants, No masses palpated.
No lesions observed
Genital/Rectal: no cervical motion tenderness, no adnexal masses.
Musculoskeletal: age related atrophy; muscle strengths 5/5 all groups.
Neurological: Alert and oriented to person, place, and time. CN II-X intact.
Skin: rashes on right arm, no radiation of rash at this time, no itching, no acne,
History of moles on left fingers
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LAB/DIAGNOSTIC TESTS/EKG: No diagnostic studies performed.
Clinical appearance is sufficient for distinctive diagnosis.
Differential Diagnosis:
- Herpes Zoster Virus (ICD-9: 053). Rash, pain and eruption of grouped vesicles in the same dermatome and fellow a segment of the body suggests herpes zoster virus. The symptoms described by ABC suggests Herpes Zoster Virus (Dains, Baumann, & Scheibel, 2019)
- Herpes Simplex Virus (ICD-9: 054). Prodrome, which can include symptoms, such as fever, malaise, loss of appetite, and localized pain and/or burning at the site the lesions will occur. Tingling and burning without lesions, to recurrent genital ulcerations. Typical widespread lesions clustered together and predilection for lips and genitalia (Dains, Baumann, & Scheibel, 2019). The rash ABC exhibits is not in the area and is on the same dermatome and is likely to be HSV (Kennedy, & Gershon, 2018).
- Contact Dermatitis (ICD-9: 692). Localized burning, stinging, itching, blistering, redness, and swelling at the area of contact with the allergen or irritant. ABC was not exposed to an allergen or environmental irritant and does not describe the rash as pruritic (Ball et al., 2019).
ASSESSMENT: Herpes Zoster Virus (ICD-9: 053).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th Ed.). St. Louis, MO: Elsevier Mosby.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
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
Kennedy, P. G., & Gershon, A. A. (2018). Clinical features of varicella-zoster virus infection. Viruses, 10(11), 609.
Question – Comprehensive SOAP
- Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week\’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
- Use medical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. 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
- Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
- Use these 2 references, plus 2 evidenced based reference
- 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.
- https://class.content.laureate.net/404149866c3bda2e192248365629d9f5.pdf
- Please see the example attachment included below to use a guide
- Please see the previous paper that someone wrote that is not acceptable by rubric, can\’t say normal, and have to use clinical medical terminology, paper is supposed to be completed and not have blanks for me to enter in the information.
