Exam (elaborations)
NUR 6111 Adv Nursing Practice 1 Module 1 Skin SOAP Note V Kobayashi
- Institution
- William Paterson University
NUR 6111 Adv Nursing Practice 1 Module 1 Skin_SOAP_Note_V_Kobayashi
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Module 1 Skin SOAP NoteVictoria Kobayashi, RN, BSN
NUR 6111- Advanced Practice Nursing I
William Paterson University
Dr. Persephone Vargas, DNP, APN-BC, FNP-BC
March 27, 2022
This study source was downloaded by 100000881663784 from CourseHero.com on 08-17-2024 09:56:08 GMT -05:00
https://www.coursehero.com/file/143572515/Module-1-Skin-SOAP-Note-V-Kobayashidocx/
, Subjective:
CC- “I’m here for this pain and rash on my back.”
HPI- Felipe Barbosa is a 48-year-old Hispanic male. Patient reports tingling in the rash area that
started four days ago followed by a rash that broke out two days ago. Patient reports pain
started with the rash two days ago described as constant burning rated at 7/10 with and
without Ibuprofen use. Patient reports Ibuprofen use of 800 mg/day taking a couple 200 mg
tablets 2-3 times per day. Last Ibuprofen dose this morning. Patient reports red, blistering rash
and pain located only at right lower back. Patient reported sweating made the pain worse and
ice pack did not relieve symptoms. Patient reports itching at site of rash but has not scratched
as he believed “that would be messy.” Patient denies radiation of pain, chest pain, abdominal
pain, and photophobia. Patient reports increased tiredness throughout the day. Patient denies
history of similar rash in the past.
PMH- Patient denies any previously diagnosed medical conditions. Patient denies history of
back pain, heart disease, spinal surgery, HIV. Patient reports chicken pox as a child. Patient
denies history of surgery, previous hospitalizations.
Medications- Ibuprofen 800mg/day prn pain. Last take this morning. Reports little relief of pain
from burning rash. (See HPI). Patient denies use of vitamins and supplements.
Allergies- Patient denies allergies to food, medications, latex, environment.
Family History- Patient denies family history of skin diseases. Patient reports father has high
cholesterol and hypertension and mother has diabetes. Both parents are still living.
Social History- Patient lives in a condo with his husband. Patient is a firefighter and reports
strong social support system including husband, family, and colleagues at the firehouse. Patient
This study source was downloaded by 100000881663784 from CourseHero.com on 08-17-2024 09:56:08 GMT -05:00
https://www.coursehero.com/file/143572515/Module-1-Skin-SOAP-Note-V-Kobayashidocx/
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