How To Assess The Skin, Hair, Nails, And Abnormal Skin Findings

Comprehensive SOAP Template This template is for a full history and physical. For this course include only areas that are related to the case. Patient Initials: __JM_____ Age: __18_____ Gender: __Female_____ SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): The patient together with his mother indicated the teenager has experienced rash and itching on both arms and right knee for the past 2 months. History of Present Illness (HPI) The 18 year old African American female reported rash and itching on the arms and right knee. This started 2 months ago, which started as red patches or spots. The locations are now whitish and this has progressed in the last two months, whereby the itching and rash have progressed especially when she scratches. However, he denies that the red spots are painful or any aggravating factors Medications: no medication Allergies: Amoxicillin rash Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations. Past Surgical History (PSH): Include dates, indications, and types of operations. Sexual/Reproductive History: Did not indicate risky sexual behaviors. Personal/Social History: Physically active, has good appetite, no eating disorder and drug abuse, Immunization History: Has recently received flu and, pneumonia immunization. Significant Family History: Mother’s family has history of stroke, CVD and asthma, while father’s family has history of diabetes. Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference. Review of Systems: General: There are no recent weight changes, weakness, fatigue, or fever HEENT: Neck: Range of motion and tracheal position in the right position, patient has normal vision without glasses, while there was no infection to the ear nose and throat. Breasts: Absence of masses, tenderness, discharges, wrinkling and skin discoloration. Respiratory: Respiration is regular and the lungs clear with chest wall symmetric. Cardiovascular/Peripheral Vascular: Regular heart and rhythm, no edema and extra sounds. Gastrointestinal: Abdomen is soft, but there are no abdominal pain, nausea or vomiting or bowel problems. Genitourinary: No urethral discharge, incontinence or history of sexually transited infectiosn (STIs). Musculoskeletal: No muscle, joint pain or recent back pain and trauma or fractures. Psychiatric: Alert, no sleep problem but has previously dealt with anxiety problems. Neurological: No history of memory loss and fainting, dizziness and abnormal movement. Skin: The skin lesions are localized in small areas. Hematologic: Endocrine: No cold and heat intolerance and endocrine symptoms. Allergic/Immunologic: No immunologic condition present. OBJECTIVE DATA Physical Exam: Vital signs: Height- 5’6, weight 120 lbs, BMI is 19.4 Blood Pressure 110/80, Pulse 90, RR 15 General The patient is attentive well developed and has no apparent distress. HEENT: Head: Her hair is short and has average texture, Eyes: Vision is normal at vision is 20/20, the pupils are round and regular they are also equal in size and react equally (4-2 mm) to light Ears: Wax does not obscure any of the ears, and can hear...