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NSG 6020 Soap Note – Atopic Dermatitis
NSG 6020 Soap Note – Atopic Dermatitis
SOAP NOTE
| Name: B. K. | Date: 6/24 | Time: 15:00 | ||
| Age: 41 | Sex: M | |||
| SUBJECTIVE | ||||
| CC:
“I have an itchy and scaly rash to my face, elbows and knees ” |
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| HPI:
41 year old male presents with erythema, itching, scaling papules to his face, elbows and knees. Patient states he has had this type of rash present for several years sporadically. Patient states it comes and goes at different times. Patient states it has become a nuisance and it itches and burns at times. He states pain at times is often 3 out of 10 severity. He complains of generalized discomfort to face, elbows and knees. Patient sometimes uses different types of topical lotions to prevent itchiness. NSG 6020 Soap Note – Atopic Dermatitis. |
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| Medications:
None |
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| PMH
Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: None Other: Immunizations: Up to date on all immunizations. Flu shot received in September of 2015. Plans to receive the flu vaccine each year. Tetanus booster received in 2015. Environmental hazards: Patient denies environmental hazards. Safety measures: Patient is a contractor and states “I always wear the necessary protective equipment”. Exercise and leisure: Exercises during work. Sleep: Denies any difficulty sleeping. Diet: Drinks one cup of coffee in the morning. Does not eat breakfast. Sometimes he skips lunch. Has dinner. |
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| Family History
Father passed away from Multiple Myeloma. Brother has type II Diabetes and Gout. |
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| Social History
High school graduate. Some college. Is a contractor and remodels kitchens and bathrooms. He is single and lives by himself. Denies tobacco and illicit drug use. Drinks socially. NSG 6020 Soap Note – Atopic Dermatitis. |
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| ROS | ||||
| General
Concerned with rash to face, elbows, and knees. Otherwise no complaints verbalized. |
Cardiovascular
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| Skin
Complains of rash to face, elbows and knees. Complains of itchy dry scaly patches of skin to face, elbows and knees. Denies any other abnormalities to the skin, hair or nails. |
Respiratory
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| Eyes
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Gastrointestinal
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| Ears
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Genitourinary/Gynecological
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| Nose/Mouth/Throat | Musculoskeletal | |||
| Breast | Neurological | |||
| Heme/Lymph/Endo | Psychiatric | |||
| OBJECTIVE | ||||
| Weight 185 lbs BMI 26.5 | Temp 98.5 | BP 123/76 | ||
| Height 5’10” | Pulse 68 | Resp 15 | ||
| General Appearance
41 year old white male. No distress noted. He responds appropriately to questions asked and makes eye contact. He is alert and oriented x3. He appears well nourished and groomed. Patient participated well during all parts of the exam. |
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| Skin
Rash is present bilaterally to the face, elbows and knees. Erythema is present to areas noted. Scaly and dry patches scattered to face, elbows and knees. No exudate noted. Crusting present. No other lesions or moles noted. |
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| HEENT | ||||
| Cardiovascular
S1, S2 with regular rate and rhythm. No abnormal heart sounds, rubs or murmurs auscultated. Capillary refill 2 seconds. +3 pulses throughout. No edema. |
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| Respiratory
Chest wall symmetrical. Breath sounds clear to auscultation. Respirations regular. NSG 6020 Soap Note – Atopic Dermatitis. |
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| Gastrointestinal | ||||
| Breast | ||||
| Genitourinary | ||||
| Musculoskeletal | ||||
| Neurological | ||||
| Psychiatric | ||||
| Lab Tests
None |
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| Special Tests
None Diagnosis …
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NSG 6020 Week 5 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 6 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 6 Physical Exam Video and Write Up Assignment
Complete Health History and Physical Assessment Write-Up Presentation
This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.
Week 7 SOAP Note Assignment
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
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Week 8 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 9 SOAP Note Assignment
SOAP NOTE
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided. NSG 6020 Soap Note – Atopic Dermatitis.
Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.