Psoriasis SOAP Note Critique “On my honor as a student, I have neither given nor received aid on this assignment.” Vitals The UVA Dermatology Department does not take vital signs. Chie f Complaint: Follow up evaluation of psoriasis Subjective: This is a pleasant 18 year old male, who presents t...
Psoriasis SOAP Note Critique “On my honor as a student, I have neither given nor received aid on this assignment.” Vitals The UVA Dermatology Department does not take vital signs. Chief Complaint : Follow up evaluation of psoriasis Subjective : This is a pleasant 18 year old male, who presents today at the Dermatology Clinic for evaluation of psoriasis. It appears that he was last seen in Dermatology Clinic approximately a year and half ago. At that time, he was noted to have a flare up of his psoriasis after receiving systemic prednisone for an asthma attack. He was prescribed Soriatane 25 mg daily as he responded well in the past. He did not fill this medication partially because of financial constraints; in addition, he was concerned about drinking wh ile at school. He has not used any topicals recently. As he could not fill the Soriatane, he was given a prescription of Keflex and Dovonex, which he used in conjunction for some period of time. This led to some improvement; however, he continues to have q uite significant psoriasis. He notes that his main concerns is that of pruritus. He is also bothered by the erythema and scaling of his skin. The patient denies any joint swelling or joint pain. He states that he has otherwise been in good health. He is cu rrently using just over the counter lotions for his psoriasis. Past Medical History : Asthma Psoriasis Medications: Albuterol Inhaler Family History: No know family history of skin cancer. He does have a history of psoriasis in an uncle and eczema in his sister. Deletions/Revisions: 1. I did not document a review of systems. a. I should have documented formally that the patient is generally in good health, by stating “negative review of systems.” Instead I briefly mentioned him being in good health in the history of presenting illness. The review of systems may uncover problems that the patient has overlooked, particularly in areas unrelated to the chief complaint (Bickley & Szilagyi, 2009). b. Legally, it is important to document review of systems for payment of services rendered. Health professionals who don't comply with the guidelines or the claims review process will be denied payment for the billed service (Centers for Medicare & Medicaid Services, 1997). For the problem -pertinent ROS such as the one presented, the documentation must show the patient's positive responses and pertinent negatives for the system related to the problem identified in the HPI (Centers for Medicare & Medicaid Services, 1997). 2. I did not inquire about the onset of original flare up, nor did I specifically date and time of recent flare up. Nor did I document, that his psoriasis got better in the summer. a. When obtaining a history, it is useful to determine the age of onset as younger age of onset and positive family hi story have been associated with more widespread and recurrent disease (Gudjonsson & Elder, 2008). 3. I did not inquire about the type of OTC medications he had been using. Nor did I add it to the medication list. a. “Medications should be noted, including name dose, route, and frequency of use” (Bickley & Szilagyi, 2009). The reconciliation of medications helps to tease out what may be the root of a patient’s illness or clinical presentation. 4. The prior course of disease was not documented for this patient. Inquiring about the prior course of disease, helps to establish patterns and guide treatment. a. Patients who frequently experience relapse tend to develop more severe disease and require more aggressive therapy; therefore, for prognostic implications, it is important to get a thorough history of the disease (Levine & Gottlieb, 2009). 5. This patient is a freshman in college. Being a freshman 4 hours away from home in a new environment could cause stress. His self – esteem or confidence may be diminished because of the unattractive skin lesions all over his body. I should have inquired about his social history more or assessed his feeling about how he’s adjusting in school. a. Lesions can cause decreased concentration, impaired sleep and/or generalized discomfort (Johnson & Armstrong, 2012). b. Associations of psoriasis with smoking and alcohol should prompt clinicians to inquire regarding social factors (Johnson & Armstrong, 2012). OBJECTIVE General: Alert, oriented, appropriate, cooperative with the exam. Well – dressed, well – nourished African American male in no acute distress. Head/Face: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp a nd preauricular cheek. Skin: Sharply demarcated erythematous and thin plaques covering 80% of his bilateral upper extremities and trunk.
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