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*NURSING > Class Notes > SOAP note adult 2 topic based 3 (All)

SOAP note adult 2 topic based 3

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SOAP note adult 2 topic based 3 S.O.A.P. Note Chief Complaint Patient complains of rash to neck, face and both arms. History of Present Illness 24-year-old male presents with a rash to his neck, ... face and bilateral arms that is spreading. He reports the rash started 2 days ago after returning home from a camping trip. Also complains of pruritis that has not been relieved with over the counter creams such as Benadryl. He denies fever and body aches. Past Medical History Past Medical history: Asthma Past surgical history: Tonsillectomy in 1993 Patient is current in his immunizations Allergies: Penicillin Current medications include: albuterol 90 mcg 2 inhalations every 4 hours PRN Family History Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses Mother: Type 2 diabetes and hypertesion Father: Asthma, and Hypertension Brother: no known medical issues Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history i [Show More]

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