NURS 6512: Advanced Health Assessment and Diagnostic Reasoning | week 4 soap note

Document Content and Description Below

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning Image #2 (Small raised red papules on chest and arms) Patient Initials: M.G. Age: 45 Gender: Male Subjective Data: Chief Complaint (C... C): “I have these tiny red spots that started on my chest and now I’m noticing them on my arms.” History of Present Illness (HPI): MG is a 45-year-old Caucasian male present with multiple small bright red papules with different shapes on his chest and his bilateral upper arms. The patient first noticed the spots in his mid-thirties but did not think much of it and now seems to be increasing in number and spreading to his upper arm. Some of the papules are slightly raised and circular while others appear flat and smaller and change to a brown color. The skin is dry and intact no drainage or broken skin noted. Patient denies any pain, itching or tenderness, no inflammation around the areas. He denies falls, injuries or trauma. Medications: 1.) Metoprolol 25mg 1tab po daily 2.) Atorvastatin Calcium 20mg 1tab po at bedtime 3.) Multivitamin tablet daily Allergies: No Known Allergies Past Medical History: Hyperlipidemia Hypertension Past Surgical History: Appendectomy 1992 Sexual / Reproductive History: Heterosexual and married with one sexual partner Personal / Social History: Denies tobacco use, smoking or using illicit drugs. Drinks occasionally twice per month. He exercises regularly and reports eating a healthy diet high in fruits, vegetables, and lean protein. Immunization History: Up to date with his immunizations. Received the influenza October of last year and pneumococcal vaccine 2y [Show More]

Last updated: 1 year ago

Preview 1 out of 5 pages