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*NURSING > SOAP NOTE > NURS 6541 Week 10 SOAP Note (All)

NURS 6541 Week 10 SOAP Note

Document Content and Description Below

NURS 6541 Week 10 SOAP Note Patient Initials: LB Age: 4-years-old Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): “dry, itchy patches to bend of arms and left wrist.” History of Present ... Illness (HPI): This is a 4-year-old African American female patient who presents with itchy patches to bilateral antecubital areas and to left wrist for two weeks with no improvement. Mother states that the child has experienced these same patches several times over the last two years but they were beginning to occur more often. Patient and patient’s mother denies any pain, burning, or drainage at sites. Mother denies any changes in laundry detergent, lotions, soaps, or medications with child. Mother states that the itching seems to worsen at night and that she has not tried any treatment therapies at site. Mother denies exposure to individuals with similar symptoms. Medications: No routine or as needed medications. Allergies: No known allergies. Past Medical History (PMH): No history of recent or past hospital administrations. No medical history. Review of Systems: General: Child appears to be well-nourished, healthy, and in no acute distress. Child appears well groomed and neatly dressed. Denies fever, chills, weight loss, loss of appetite, or fatigue. HEENT: no visual disturbances or changes, denies sensitivity to light, hearing disturbances or ear pain, nasal congestion or discharge, sneezing, throat pain, difficulty swallowing, or cough References Barry, M. (2018). Scabies. Retrieved from https://emedicine.medscape.com/article/1109204- overview Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.) (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier. Feldman, S. R. (2018). Epidemiology, clinical manifestations, and diagnosis of psoriasis. Retrieved from https://www.uptodate.com/contents/epidemiology-clinicalmanifestations-and-diagnosis-of-psoriasis Fenstermacher, K. & Hudson, B. T. (2016). Practice guidelines for family nurse practitioners (4th ed.). St. Louis, Missouri: Elsevier. [Show More]

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