1
NUR 6512N
Comprehensive Soap NoteWeek4 Skin Comprehensive SOAP Note
(complete) / SOAP NOTE on Striae Gravidarum.
Comprehensive Soap Note
Week 4 Assignment 1
Nursing 6512N
Jessica Toney
Walden University
This study source was downloaded by 100000832558064 from CourseHero.com on 03-23-2022 01:06:48 GMT -05:00
https://www.coursehero.com/file/33503683/Nursing-6512-Week-4-Assignment-1docx/
, 2
NUR 6512N
Comprehensive Soap NoteWeek4 Skin Comprehensive SOAP Note
(complete) / SOAP NOTE on Striae Gravidarum.
Comprehensive SOAP
Patient Initials: JS Age: 58yo Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Skin abnormality appearance of a wide array of firm red bumps
on chest and upper stomach (Slide #2)
History of Present Illness (HPI): JS is a 58-year-old white male who appears today to
address numerous red bumps on his chest that spreads down to his abdomen. He reports
there is a gradual onset over the past few months and he did not have this many a few
years ago. He is concerned he may have cancer since he asked some friends and they said
it could be start of it. He denies any pain to the areas, exudate, bleeding, or change in
shape. He denies any fever and no presentation to contact aggravations such as
chemicals. States his job can be a little stressful at times but not too significant. No
changes in lifestyle. He does not have any personal history of skin growths before other
than moles but there is a family history of skin cancer.
Medications:
Celexa 20mg daily
Metoprolol 25mg BID
Allergies:
Amoxicillin
Past Medical History (PMH):
Depression: diagnosed at age 37
Hypertension: diagnosed at 46
Past Surgical History (PSH):
Lasik Eye Surgery (Dr. John Stefano, MD), age 47
Cholecystectomy (Dr. Anil Makani, MD), age 54
Appendectomy (Surgeon Unknown), age 16
Sexual/Reproductive History:
Heterosexual, he is currently sexually active with one partner. He uses no barrier
methods and his wife has entered menopause.
Personal/Social History:
Never smoked, occasional ETOH use (5 wine coolers per month), denies any use
of illicit drugs
Immunization History:
This study source was downloaded by 100000832558064 from CourseHero.com on 03-23-2022 01:06:48 GMT -05:00
https://www.coursehero.com/file/33503683/Nursing-6512-Week-4-Assignment-1docx/
NUR 6512N
Comprehensive Soap NoteWeek4 Skin Comprehensive SOAP Note
(complete) / SOAP NOTE on Striae Gravidarum.
Comprehensive Soap Note
Week 4 Assignment 1
Nursing 6512N
Jessica Toney
Walden University
This study source was downloaded by 100000832558064 from CourseHero.com on 03-23-2022 01:06:48 GMT -05:00
https://www.coursehero.com/file/33503683/Nursing-6512-Week-4-Assignment-1docx/
, 2
NUR 6512N
Comprehensive Soap NoteWeek4 Skin Comprehensive SOAP Note
(complete) / SOAP NOTE on Striae Gravidarum.
Comprehensive SOAP
Patient Initials: JS Age: 58yo Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Skin abnormality appearance of a wide array of firm red bumps
on chest and upper stomach (Slide #2)
History of Present Illness (HPI): JS is a 58-year-old white male who appears today to
address numerous red bumps on his chest that spreads down to his abdomen. He reports
there is a gradual onset over the past few months and he did not have this many a few
years ago. He is concerned he may have cancer since he asked some friends and they said
it could be start of it. He denies any pain to the areas, exudate, bleeding, or change in
shape. He denies any fever and no presentation to contact aggravations such as
chemicals. States his job can be a little stressful at times but not too significant. No
changes in lifestyle. He does not have any personal history of skin growths before other
than moles but there is a family history of skin cancer.
Medications:
Celexa 20mg daily
Metoprolol 25mg BID
Allergies:
Amoxicillin
Past Medical History (PMH):
Depression: diagnosed at age 37
Hypertension: diagnosed at 46
Past Surgical History (PSH):
Lasik Eye Surgery (Dr. John Stefano, MD), age 47
Cholecystectomy (Dr. Anil Makani, MD), age 54
Appendectomy (Surgeon Unknown), age 16
Sexual/Reproductive History:
Heterosexual, he is currently sexually active with one partner. He uses no barrier
methods and his wife has entered menopause.
Personal/Social History:
Never smoked, occasional ETOH use (5 wine coolers per month), denies any use
of illicit drugs
Immunization History:
This study source was downloaded by 100000832558064 from CourseHero.com on 03-23-2022 01:06:48 GMT -05:00
https://www.coursehero.com/file/33503683/Nursing-6512-Week-4-Assignment-1docx/
