Description
Fill Up the SOAP Note (See my Friends example paper for her SOAP notes) and make it similar but different story for example make similar format using different DATA for the same diagnose (Straie)
those are the diagnosis you will use it im my assignment they are 5 differential and primary
ASSESSMENT:
Differential Diagnosis (DDx):
1)Skin rash
2)Purpura
3)Lichen Striatus:
4)Sturge-Weber Syndrome
5)Linear Scleroderma
Primary Diagnoses:
Striae atrophicae
1-2 page, including introduction, purpose statement, and conclusion. Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of five possible conditions for the skin graphic that you chose (already chosen at the end of the attached file). Determine which is most likely to be the correct diagnosis (Striae atrophicae) and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search (last 5 years with doi) and two different references from this week’s Learning Resources.
Course references
1)Bonifant, H., & Holloway, S. (2019). A review of the effects of ageing on skin integrity and wound healing. British Journal of Community Nursing, 24(Sup3), S28–S33. https://doi.org/10.12968/bjcn.2019.24.sup3.s28
2) 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. —->attached pdf file
Unformatted Attachment Preview
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _MN___
Age: 35____
Gender: Female_______
SUBJECTIVE DATA:
Chief Complaint (CC): Picture 2. Concern regarding the appearance of stretch
marks on the abdomen.
History of Present Illness (HPI): The patient is a 35-year-old female who
presents with a chief complaint of concern regarding the appearance of stretch
marks on the abdomen and breasts. The patient reports that these marks initially
developed during a period of rapid weight gain, specifically during pregnancy
approximately 5 years ago. The patient describes the initial appearance of the
stretch marks as reddish-purple lines on the abdomen and breasts, which have
since faded to a lighter color. The patient denies experiencing any associated
pain, itching, or other symptoms related to the stretch marks. The appearance of
the marks has remained the same. The patient notes that attempts to mitigate
the appearance of stretch marks through over-the-counter remedies have been
unsuccessful. The patient has not sought prior medical attention for the stretch
marks and is seeking evaluation for cosmetic concerns and information on
potential treatment options. The patient reported no relevant family history or
additional medical issues related to the chief complaint.
Medications:
1) Vitamin D3 50 mcg daily.
2) Atorvastatin 10mg daily.
Allergies:
No known allergies
Past Medical History (PMH):
1) Vitamin D deficiency.
2) Hyperlipidemia.
Past Surgical History (PSH):
1) Cesarean section 2018.
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
Married
Number of Children: One, born in 2018
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Never smoked
Lives with her husband
Works as a social worker in a nearby hospital.
Health Maintenance:
Schedules routine check-ups with healthcare professionals
Engages in regular physical activity
Schedules regular eye/dental exams
Adheres to medication regimen
Immunization History:
Covid Vaccine #1 1/5/2021 #2 2/22/2021 Pfizer
Influenza Vaccination 10/3/20223
Tdap 8/22/2018
Significant Family History:
Father – with stroke in 2016
Mother – with diabetes dx at age 40
Two healthy living younger sisters.
Review of Systems:
General: No complaints of fatigue, weakness, or unexplained weight loss.
HEENT: The head is normocephalic and atraumatic, with no tenderness or
palpable masses. In the eyes, pupils are equal, round, and reactive to light,
extraocular movements are intact, and the conjunctiva is clear with a white
sclera. The ears show a normal external appearance, intact and pearly
gray tympanic membranes, and no reported pain or discharge. The nose
exhibits pink and moist nasal mucosa, a midline septum, and no discharge
or tenderness. Throat examination reveals a clear oropharynx, moist
mucous membranes, and normal tonsils, with no erythema, exudate, or
lesions.
Respiratory: denies cough, denied hemoptysis, no difficulty
breathing at rest; no dyspnea on exertion.
Cardiovascular/Peripheral Vascular: denies chest discomfort,
palpitations, or a history of murmurs. No reported or documented history of
arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or
claudication.
Gastrointestinal: denies nausea or vomiting, with well-controlled reflux.
No reported abdominal pain; no alterations in bowel or bladder patterns.
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Incorporates fiber into their daily regimen as a laxative to prevent
constipation proactively.
Genitourinary: denies change in her urinary pattern, dysuria, or
incontinence.
Musculoskeletal: denies arthralgia or myalgia and reports no arthritis,
gout, or limitations in range of motion. Denies history of trauma or
fractures.
Neurological: denies neurological problems, including headaches,
dizziness, seizures, numbness, or tingling. Denies any recent changes in
cognition, memory, or speech.
Psychiatric: denies any psychiatric problems, including changes in mood,
anxiety, depression, or disturbances in sleep patterns. Reports no recent
episodes of panic attacks or suicidal thoughts.
Skin/hair/nails: denies any issues with the skin, hair, or nails, excluding
the presence of stretch marks on the abdomen. No complaints of itching,
pain, or changes in skin texture were reported.
OBJECTIVE DATA:
Physical Exam:
Vital signs: B/P 121/78, right arm, sitting, regular cuff; P 77 and regular; T 97.6
temporally; RR 18; non-labored; Wt: 140 lbs; Ht: 5’1; BMI 26.5
General: A/O x4, well-nourished, no acute distress; No signs of pallor, jaundice,
or cyanosis observed.
HEENT: normocephalic and atraumatic; no tenderness or palpable masses;
PERRLA; EOMI; normal appearance of ears, no pain or discharge; pink and
moist nasal mucosa, a midline septum, and no discharge or tenderness; clear
oropharynx, moist mucous membranes, and normal tonsils, with no erythema,
exudate, or lesions.
Neck: palpable carotids; no bruits; no JVD, no tenderness or thyromegaly
Chest/Lungs: Clear breath sounds throughout lung fields; normal respiratory
rate of 18 breaths per minute; symmetrical chest wall expansion; no use of
accessory muscles,
Heart/Peripheral Vascular: RRR, no murmur, rubs, or galops; S1 S2; +2
bilateral pedal and radial pulses.
Abdomen: Bowel sounds are present in all quadrants, soft, non-tender upon
gentle pressure; symmetrical with no visible signs of distension, discoloration, or
abnormalities; skin is intact, with no lesions or rashes noted; brownish color
striae noted.
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Genital/Rectal: The patient declined this exam.
Musculoskeletal: 5/5 strength in upper and lower extremities; full ROM in all
extremities; normal curvature of the cervical, thoracic, and lumbar spine.
Neurological: Cranial nerves II – XII grossly intact; DTR’s intact; +2 bilateral
reflexes; Steady gait.
Skin: Skin normal color, texture and turgor with no lesions or eruptions.
Diagnostic results:
No diagnostic tests were ordered.
ASSESSMENT:
Differential Diagnosis (DDx):
1) Skin rash
2) Purpura
3) Morphea
4) Linear Scleroderma
5) Ecchymosis
Primary Diagnoses:
1) Striae atrophicae
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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