Running head: Episodic SOAP Note: Tom Walker
Episodic SOAP Note: Tom Walker
University of Phoenix
By
Yolundia Stepney
Collage of Nursing – Online Campus
NPR 531 ADVANCED HEALTH ASSESSMENT I
JANINE SUTTER
10/15/20
...
Running head: Episodic SOAP Note: Tom Walker
Episodic SOAP Note: Tom Walker
University of Phoenix
By
Yolundia Stepney
Collage of Nursing – Online Campus
NPR 531 ADVANCED HEALTH ASSESSMENT I
JANINE SUTTER
10/15/2018
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2
Running head: Episodic SOAP Note: Tom Walker
Episodic SOAP Note: Tom Walker
DOS: 10/14/18
ID: Tom Walker (M)
DOB: 1/3/75 (45)
CC: Atopic Dermatitis (eczema)
Right Knee Injury
Subjective
HPI: Mr. Tom Walker is a 45-year old is a Caucasian male who appears well groomed and a
reliable historian. He presents today with itching has been so bad that it is keeping him awake at
night, and his skin has little cracks that bleed. He has been using OCT hydrocortisone cream for
flares. His eczema flare in the bend of his arms is (9/10). He loves to take hot showers, but
notices he itches more after them. He has had these flareups on occasion in the past.
HPI: Tom injured his right knee while playing basketball 4 days ago. He hasn’t been able to bear
weight on his knee and is using crutches. He felt a “pop” and had to be carried off the floor. The
swelling and bruising are intense. He has been using ice, resting, elevating his knee, and wearing
an ace bandage on his knee for support. He reports pain (7/10). He has been taking Tylenol XS.
Past Medical Hx: Meniscus Tear 2009
Surgical Hx: Tom had a meniscus repair with a scope on the same knee in 2009. He also had an
appendectomy last August.
Family Hx: His mother has elevated cholesterol and his brother is obese with high blood
pressure.
Medications: NKDA OTC hydrocortisone cream, Tylenol®
XS
Social Hx: He is a non-smoker but reports smoking pot one time in college. He drinks about 4–
6 beers per night. Tom’s mother is an RN in New Jersey
Education Level: College Graduate
Objective
PE: VS: BP - 120/78 P - 70 R - 16 T - 98.2 HT:72’ WT:250# BMI: 33.9.
General: He is a well-nourished, well developed male who appears in distress as evidence by
being unable to bear weight on his knee and is using crutches.
HEENT: Pupils are equal, round, and reactive to light and accommodation
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3
Running head: Episodic SOAP Note: Tom Walker
CV: Normal S1, S2; no S3, S4 with no murmurs or extra sounds
Pulm: Breath sounds clear; no wheezes, rales, or rhonchi noted
Abdomen: Bowel sounds active in all quadrants; soft, non-tender to palpation; nondistended.
Pt denies differences in vision, double vision, blurry vision; no congestion, no hearing loss; no
chest pain, SOB, heart palpitations; no changes in appetite; no changes in mood or memory.
Relevant specialty tests:
No tests with Atopic Dermatitis
Lachman’s test- the patient lays on the table with leg bent at a 30-degree with the foot flat, and if
the knee moves freely without reaching a firm point is a tear (Bickley, L. S., Szilagyi, P. G., &
Bates, B., 2017).
Pivot shift test- the injured leg is extended, and the foot is rotated at the same time as pressure is
applied to the outside of the knee as the knee is bent. Instability in the tibia suggests an ACL tear
(Hong, E., Kraft M.C., 2014).
Right knee x-ray to r/o fracture (Domino, F.J., Baldor R.A., Golding, J., Stephens, M., 2018).
5 Open-Ended Questions
Mr. Walker how long have you had Atopic Dermatitis (eczema)? The onset of atopic
dermatitis in childhood is most common in patients, and onset after 30 is very uncommon. What
treatments have you tried in the past that have made your symptoms better or worse? Patients
with atopic dermatitis should not bath more than once daily. Do you have any family history of
allergic reactions? Establishes if patient has a family sensitivity to irritants. When do you notice
that you flare ups tend to occur? Atopic individuals are sensitive to low humidity and often flare
in the winter (Thomsen, S.F
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