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SOAP Note Health Assessment (NURS 3020 ) Week 4

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Sandra Watson
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SOAP Note Health Assessment (NURS 3020 ) Week 4 Walden University

PATIENT NAME: David Wampler AGE: 57
SEX: Male DOB: October 13, 1960
Subjective Data
CHIEF COMPLAINT:
“I have itchy areas of skin on my arms (image #5) and red blister looking things (image #2) on my stomach.” HISTORY OF PRESENT ILLNESS: 55-year-old male patient presents to the clinic with complaints of pruritus, dry, scaling plaques on posterior of forearms. The patient recalls that the plaques started out “smaller a couple months back” and have progressively grown in size. He states that the pruritus is aggravating at times but denies experiencing any pain or other associated symptoms. In addition, an over the counter lotion was applied to the affected areas with no relief of symptoms. The patient also expresses concern about some cherry red, discoid,
papules that are present on his torso. He explained that they have been present for years but after his dog jumped on him and scratched one became concerned as it began bleeding. He denies any associated symptoms or exacerbating factors of the papules.

PAST MEDICAL HISTORY:
Medical:
1. Hypertension: diagnosed at age 45
2. Coronary artery disease: diagnosed at age 56
Surgical:
Medications:
1. Aspirin 81mg PO daily
2. Simvastatin 20mg PO daily
3. Lisinopril 20 mg PO daily
Allergies: Penicillin –causes a rash
Health maintenance: Mr. Wampler presents annually for a routine physical exam. Most recent bloodwork was 2 years ago at annual exam.
Immunizations: Mr. Wampler’s immunizations are current and annual influenza is up to date as of September of 2016.
FAMILY HISTORY: Father deceased at age 75 from MI and mother is 73 and also has hypertension and coronary artery disease. Mr. Wampler has no siblings and reports both of his daughters are in good health with no significant health history.
PSYCHOSOCIAL HISTORY: Mr. Wampler is married and resides with his wife. Both children are grown, married, and not residing in the home. Mr. Wampler has a master’s degree and is banking consultant and business owner receiving medical and health benefits through 

 

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SOAP Note Health Assessment (NURS 3020 ) Week 4

 

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