HEALTH ASSESSMENT SKIN
CONDITION
ADVANCED HEALTH ASSESSMENT
(WALDEN UNIVERSITY)
2024
, lOMoARcPSD|44613495
SOAP NOTE
Differential Diagnosis for Skin Conditions
Skin Condition Picture # 5
Patient Initials: __AJ___ Age: __24___
Gender: __F___
SUBJECTIVE DATA:
Chief Complaint (CC): Painful rash and joint pain
History of Present Illness (HPI): Anna James is a 24-year-old Caucasian
female who presents today with a new onset of a painful plaque-like rash
and joint pain 3 weeks ago. She reports she first noticed the rash on her
knees and it has now developed on her elbows and scalp. She also reports
that the rash is sore and slightly itchy. Anna has also noticed achy joints as
well throughout the last 3 weeks. She reports that stressful situations seem
to exacerbate the issue. She has changed laundry detergent and noticed no
improvements in the rash, and she has also been taking Ibuprofen 400mg 3
times a day most days with little relief in pain. Anna reports the severity of
her rash and joint pain to be 6/10.
Medications:
1 Over-the-Counter Ibuprofen 400mg PO every 6 hours as needed 2
Women’s Multivitamin 1 tablet PO daily 3 Ortho Tri-Cyclin 1 tablet PO
daily
Allergies: No known drug or food allergies.
Past Medical History (PMH):
1 Varicella 2 Recurring tonsillitis 3 Appendicitis
CONDITION
ADVANCED HEALTH ASSESSMENT
(WALDEN UNIVERSITY)
2024
, lOMoARcPSD|44613495
SOAP NOTE
Differential Diagnosis for Skin Conditions
Skin Condition Picture # 5
Patient Initials: __AJ___ Age: __24___
Gender: __F___
SUBJECTIVE DATA:
Chief Complaint (CC): Painful rash and joint pain
History of Present Illness (HPI): Anna James is a 24-year-old Caucasian
female who presents today with a new onset of a painful plaque-like rash
and joint pain 3 weeks ago. She reports she first noticed the rash on her
knees and it has now developed on her elbows and scalp. She also reports
that the rash is sore and slightly itchy. Anna has also noticed achy joints as
well throughout the last 3 weeks. She reports that stressful situations seem
to exacerbate the issue. She has changed laundry detergent and noticed no
improvements in the rash, and she has also been taking Ibuprofen 400mg 3
times a day most days with little relief in pain. Anna reports the severity of
her rash and joint pain to be 6/10.
Medications:
1 Over-the-Counter Ibuprofen 400mg PO every 6 hours as needed 2
Women’s Multivitamin 1 tablet PO daily 3 Ortho Tri-Cyclin 1 tablet PO
daily
Allergies: No known drug or food allergies.
Past Medical History (PMH):
1 Varicella 2 Recurring tonsillitis 3 Appendicitis
