1 Differential Diagnosis for Skin Condition Walden University NURS 6512 Elizabeth Cayce Chavis June 22, 2018
2 Comprehensive SOAP Template Patient Initials: AQ Age: 41 Gender: M SUBJECTIVE DATA: “I have a dry rash, that’s peeling and itching and is getting worst.” Chief Complaint (CC): Skin condition #5. Skin abnormality noticed approximately 3 weeks ago and has gotten progressively worst in dryness and some bleeding to the site. The site is primarily the neck and chest region. History of Present Illness (HPI): AQ is a 41-year-old male who presents to the clinic with patchy, flaky, and scaly skin on the neck and chest regions. The patient states that the onset of this condition was approximately 2-3 weeks ago and has gotten progressively worst. The patient states that he has not made any major changes to his skin care products to warrant this dryness. The patient’s occupation as an accountant has recently triggered some stressful situations with recent layoffs, which he states may be a contributing factor to his condition. There is no pain associated, however, discomfort is reported. He has tried Aveeno cream and states this provides some temporary relief to the dryness and itching. Medications: 1) Pantoprazole 40 mg PO Daily
3 2) Aspirin 81 mg PO Daily Allergies: Penicillin (Anaphylaxis as a child) Past Medical History (PMH): Esophagitis, Right Bundle Branch Block Past Surgical History (PSH): Tonsillectomy Sexual/Reproductive History: N/A Personal/Social History: Drinks socially, denies tobacco use, no risky sexual behavior has one partner, patient is married.
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