SOAP Note 2 Graded.docx Sample PDF

Preview

Summary

SOAP note...

Description

SOAP Note #2 Graded NURS 6210 July 12, 2017 SUBJECTIVE Chief Complaint: “I’ve been experiencing redness on my cheeks and nose for the past month. “ HPI: Mrs. F is a 38 year-old Caucasian female presenting to the office today complaining of facial redness. It started 4 weeks ago and occurs daily, with no known trigger. The redness only occurs to her cheeks and nose at various times of the day and has no associated symptoms. She denies pruritis, chills, fever, or pain. She has not tried any medication to relive it. Mrs. F has seen her Rheumatologist for it 1 month ago and thinks that it may be rosacea. PMH: Oral contraceptive use, UTI, anxiety with panic attacks, chronic fatigue, chronic ear and sinus infections. PSH: Breast aspiration, left, 01/2012 Right breast cyst aspiration, left breast needle Local partial mastectomy, 8/2012 Right breast cyst aspiration, 1/2013 Excisional biopsy right upper back 4/2015 Family Hx: Mother- alive, 71 years, rheumatoid arthritis, diagnosed with HTN, diabetes Father- deceased 63 years, diagnosed with diabetes, HTN, heart disease, heart attack, stroke. Paternal grandfather- deceased, diagnosed with heart disease. Paternal grandmother, deceased, heart failure. Maternal grandfather, alive, rectal cancer Maternal grandmother, alive, asthma. 1 brother, 1 sister, healthy. No children Social Hx: Tobacco use: 17 pack years, quit on 11/2016. Never an alcohol user. Caffeine: 2 cups of coffee daily. Soda/Pop, rarely. No street drug use. Divorced, works part-time in an outdoor setting. Walks frequently for work, eats a mostly balanced diet and sleeps 7 hours per night. Feels rested during the day. OB/GYN:

Monogamous relationship Last menstrual period 7/2017 Gynecologist: Dr. Anonymous Last PAP Smear: 8/2014 Last mammogram: 2012 Current Medications: Ativan (Lorazepam) 0.5mg 1 tablet QAM PRN Elavil (Amitriptyline) 25-50mg tablet oral HS PRN Evoxac (Cevimeline HCl) 30mg capsule BID Flonase (Fluticasone Propionate) 50mcg suspension 1 spray nasally QD PRN Lialda (Mesalamine) 1.2gm tablet oral QD Plaquenil(Hydroxychloroquine Sulfate) 200mg tablet oral BID Restasis (Cyclosporine) 0.05%emulsion 1 drop into affected eye QD YAZ (Drospirenone-Ethinyl Estradiol) 0.06mg tablet oral QD Allergies: Zithromax Z-Pak: severs abdominal pain Bromfed: vomiting, tremors Bactrim DS: chemical taste ROS: General- Denies Depression. Anxiety stable with occasional Ativan use. Denies Mood Swings. Denies fever, chills, nausea. EENT- Denies tinnitus, ear, eye, nose, or throat pain. Cardio- Denies chest pain Pul- Denies SOB GI- BM’s and urination ok. OBJECTIVE Vitals: Ht 63.2 inches, Weight 111 lbs, BMI 19.54, BP sitting 114/76, HR 92/min, Temp 98.8, RR 16. General Survey- Well-developed, well groomed, well-nourished Psychological- Alert and oriented, no acute distress. Head- Normocephalic, atraumatic. Sinuses non-tender Eyes- PERRLA, no erythema or drainage Ears- Equal size bilaterally, with no swelling or thickening. Skin intact, pinna and tragus firm and non-tender. No swelling, redness, or discharge. External canal free of redness, swelling, or lesions. Tympanic membrane is shiny and translucent and flat. Whisper test negative. Nose- turbinates red, smooth, and boggy Throat- tongue smooth, pink & moist. Soft palate pink, smooth, and upwardly movable. Tonsils 1+, normal breath odor. Pulmonary- Lung sounds clear, no adventitious sounds noted. Respirations even and unlabored. Chest symmetric, no tenderness or crepitus noted.

Cardiovascular- Heart sounds normal S1 S2, regular, no murmurs, rubs, or gallops noted. GI- Active bowel sounds X4, soft and non-distended, no rebound or rigidity, no masses or tenderness noted. Aorta midline, no pulsatile mass, no abdominal bruit. Musculoskeletal- Normal gait, normal strength, no atrophy or abdominal movements noted. Skin: mild erythema to face, blanchable

DIAGNOSIS AND PLAN Differential Diagnosis #1: Autoimmune Dermatitis (Eczema) Discussion: IN: This patient has Raynaud’s disease, so other autoimmune issues such as eczema are likely. Eczema is one of the most common skin conditions (Fenstermacher, 2016) Symptoms with Eczema include lesions commonly seen on face and trunk (Cash and Glass, 2016). Flare-ups are often associated with cosmetics(Fenstermacher, 2016) and patient wears makeup. OUT: The redness continued despite a recent course of oral prednisone therapy and Plaquenil, which she had already been taking for her Raynaud’s. The redness was well covered by patient’s cosmetics, so it did not resemble eczema seen in textbook photographs(Fenstermacher, 2016). Risk Factors/Predisposing Factors: Family history of dermatitis, asthma, and allergic rhinitis(Cash and Glass, 2016). Exposure to skin irritants such as harsh soaps, skincare products, perfumes with chemicals and alcohol, fabrics containing wool, or tight clothing(Cash and Glass, 2016).

Differential Diagnosis #2: Contact Dermatitis Discussion: IN: Irritation to the skin causing erythema. Patient applied possible irritants to her face. OUT: While patient has used cosmetics, usually contact dermatitis is caused by exposure to more inflammatory agents such as chemicals, solvents, or cold, dry air. Affected areas only occur to the cheeks, and not the forehead areas where the same cosmetic products were used. Risk Factors/Predisposing Factors: People who work with chemicals, yard work, jewelry.

Differential Diagnosis #3: Seborrhoeic Dermatitis Discussion: IN: “A common chronic, erythematous, scaling dermatosis, seborrheic dermatitis occurs in areas of the most active sebaceous glands such as the face and scalp, body folds, and presternal region”(Cash and Glass, 2017). OUT: Often accompanied by dandruff and an itchy scalp, which patient did not have. Usually appear as raised plaques, whereas patients skin appeared smooth. Risk Factors/Predisposing Factors: Family History, living in warmer climates(Cash and Glass, 2017). HEALTH RISKS If Autoimmune Dermatitis persists, it can spread throughout the body. Refer to dermatologist if it does not clear in 10-14 days (Cash and Glass, 2016). PLAN 1. Autoimmune Dermatitis (Eczema) Plan- Betamethasone valerate 0.1% two to three times daily. Discontinue cosmetics that are not hypoallergenic. Continue gentle cleansers such as Cetaphil or Cerave when bathing. Patient teaching- Indicate possibility of hypopigmentation of skin from short-term use of steroids on skin(Cash and Glass, 2016). Call office if not resolved within two weeks. 2. Raynaud’s Disease (Chronic) Plan- Refill Plaquenil(Hydroxychloroquine Sulfate) 200mg tablet oral BID. Consume low-sodium, heart healthy diet. Continue tobacco cessation and avoid exposure to second-hand smoke. SELF EVALUATION This patient was a challenge, since there was little information to use as far as the physical exam, other than some scant redness to her face. All other assessment aspects were negative. Since she reported no associated symptoms, I had to rely on her history and consider the differentials of experiencing redness to the face. As a current patient of our clinic, I fortunately had a significant amount of information relating to her medical history. I was able to get an overall picture of her health before walking in to the room. She was articulate and terse in her response to my questions, which was helpful. I have found that some patients we see do not give concise, to the point answers- or others are reluctant to elaborate much. So this patient seemed reliable in articulating her history of present illness. I have learned to redirect some patients in getting to the point in their responses. To make a more accurate diagnosis, it would have been helpful for her to have visited the office without any makeup on. Also, pictures from earlier in the week when the symptoms may have been more pronounced would have assisted in the diagnostic reasoning process.

If I could do this visit a second time, I would have inquired more about potential irritants to the face. I have found that a sizeable number of our skin conditions end up being contact dermatitis from a variety of household and outdoor elements. So even though we determined autoimmune dermatitis to be the diagnosis, it’s possible we missed contact dermatitis. Although, the treatments for the two conditions are similar. One other aspect I would go further into is tobacco cessation. While she claimed to have stopped smoking completely, she admitted that since many of her family and friends smoke, she will breathe some of their second-hand smoke as a way of reliving her cravings. And that of course could worsen her Raynaud’s and dermatitis. So I would have emphasized tobacco cessation strategies and products more. In thinking further, I realized that information regarding the patient can be limited, despite how much time and effort I put forth. When information is limited, of course I want to consider how to seek out more of it before jumping to conclusions. Fortunately with this condition, the treatments for the differentials were similar, and relatively low-cost. I had also ruled out any known serious conditions and knew that she was set to see her Rheumatologist for an appointment in one month. So collectively we were comfortable selecting a low-dose steroid cream with appropriate follow-up. This case was useful for me to work on since it involves a common issue in primary care. This will help me to be better prepared to treat the numerous skin conditions that visit our unit seeking help. Resources Cash, J. C., & Glass, C. A. (2017). Family practice guidelines. New York: Springer Publishing Company, LLC. Fenstermacher, K., & Hudson, B. T. (2016). Practice guidelines for family nurse practitioners. Philadelphia, PA: Elsevier....