1 Comprehensive Soap Note Shelley Ison Walden University NURS 6512, Section 18, Advanced Health Assessment 03/18/2019
2 Comprehensive SOAP Patient Initials : BI Age : 48yo Gender: Male SUBJECTIVE DATA: Chief Complaint (CC): Skin abnormality on the upper torso and abdomen. The appearance of a round to oval, bright red, domed shaped papules ranging in size. (Slide #2) History of Present Illness (HPI): BI is a 48-year-old white male who presents to the office with numerous “red moles” on his upper torso and abdomen. BI admits over the course of six months he has noted gradual onset from an initial appearance on his chest gradually spreading to his abdomen with an increase of size. He is concerned that the spread of these “red moles” along with the increase in size he may have skin cancer. He denies any pain at the site or bleeding. He denies fever, weight loss, and any recent contact with any aggravating compound chemicals. He works as an Internet Technician (IT) Network Engineer Manager from home and reports his job can be somewhat stressful at times. In the summer he is active outdoors on riding his tractor and admits at times he does work in the sun without a shirt. He denies any previous history of significant skin growths and no family history of skin cancer. Medications: Protonix 40 mg daily Losartan 50 mg daily Allergies: NKDA Past Medical History (PMH): Gastroesophageal Reflux Disease (GERD): diagnosed at age 37 Hypertension: diagnosed at 45 Past Surgical History (PSH): Tonsillectomy (Surgeon Unknown), age 10 Sexual/Reproductive History: Married. Heterosexual. Monogamous. Denies the use of contraceptives due to his wife has had a tubal ligation. Personal/Social History: Never smoked, denies any ETOH use, denies any use of illicit drugs. He reports a sedentary lifestyle with little time to exercise due to the nature of his job. His diet is reported to mainly consist of high fats and high carbs from fast food and dining out.
3 Immunization History: Immunizations are said to be up to date. Last known flu shot was October 2018. Pneumococcal vaccine has not been administered. Significant Family History: Mothers history is Diabetes Mellitus Type II, Hypertension, Hyperlipidemia, and Multiple Sclerosis. Mother died January 2016 due to complications of infection from a pressure wound related to decline in functional status related to Multiple Sclerosis. Father is living; a significant history of Diabetes Mellitus Type II, Hypertension, Hyperlipidemia, and Benign Prostate Hypertrophy. One sibling age 45 without any medical history. He has one son age 28 and three daughters ages 25, 21, and 18 with no reported medical history.
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