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Skin Soap Note Differential Diagnosis for Skin Condition NURS 6512

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Sandra Watson
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Differential Diagnosis for Skin Condition Walden University

NURS 6512

0mprehensive 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: OC Age: 41 Gender: M Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
L =location
O= onset
C= character
A= associated signs and symptoms
T= timing
E= exacerbating/relieving factors
S= severity
 SUBJECTIVE DATA: “I have a sort of 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): OC 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

 

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Skin Soap Note Differential Diagnosis for Skin Condition NURS 6512

 

 

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