Download NKU clinical SOAP note and more Papers Nursing in PDF only on Docsity!
SOAP Note # Student Name: Course: MSN 651L Today’s date: September 20th, 2025 ====================================================================================== Demographics: J.O is a 48-year-old White Male Visit Date: September 18th,^2025 Clinical Location: New Pt. SUBJECTIVE: Chief Complaint: “I haven’t had a primary doctor in a while, and I have had this rash on my face for about 5 months.” Source & Reliability of History: Self-report from patient; patient is a reliable historian. HPI: J.O is a 48-year-old W male here to establish care and discuss rash on face for the last 5 months. Pt reports red rash over cheeks, mid forehead, and lower chin over the last months without change. Pt states sometimes itchy and he has noticed clear pustules and drainage occasionally. Denies pain in the face. Pt also reports a history of alcohol abuse but states he has been sober for two years and is following journey recovery. Pt states he is also dealing with a chronic wound on his left lower leg that is being managed by wound care weekly. PMH: Alcohol Abuse History of DVT MRSA in wound HTN Medications : Apixaban (Eliquis) 2.5mg tab daily- blood thinner to prevent DVT
Losartan (Cozaar) 50mg tab daily- ARB to treat HTN (states has not been taken for 2 weeks because he ran out) Vivitrol IM Q 28days- to treat EtOH independence and prevent relapses PSH: (Surgical history): Fasciotomy right leg- 1998 Wound debridement- unsure of dates Family History: Mother (living)- osteoporosis Father- States unsure of health history- also unsure if living or deceased as he has no contact Sister - No known health issues No Children Maternal Grandmother (deceased)- Lupus Maternal Grandfather- (deceased)- Unsure of health conditions Paternal Grandmother (deceased)- Unsure of health conditions Paternal Grandfather (deceased)- Unsure of health conditions Social determinants of health: Insurance- Caresource IN HIP Medicaid Tobacco: former smoker-quit in 2020 Alcohol: Sober for 2 years- states alcoholic for 10 years prior to that Illicit drug: Not currently- history of marijuana, opioids Environmental exposures: Unsure- homeless for on and off periods of time Safety Assessment: Depression Screening PHQ9: 0 Reports feeling safe at home: Yes Living situation: Lives in apartment alone Vaccinations/Immunizations:
- TDAP- 9/18/
- Covid- 11/18/
- Hep A- 7/22/ Flu Vaccine- 9/18/
Psychiatric: Pt denies feelings of depression or anxiety. Pt denies hallucinations, self-injury, sleep disturbance and suicidal ideas. OBJECTIVE: Physical Exam: General appearance: Pt is calm and cooperative with no acute distress. Pt is appropriately dressed. Pt appears well nourished but overweight Vital signs: BP 164/90, HR- 65, RR-18, O2- 97% RA, Temp.-98. Height: 6’ Weight: 244lbs BMI: 31. Skin: General: skin is warm and dry, no suspicious moles or lesions- red macular rash noted to bilateral cheeks, nose, mid forehead and chin - Coloration: Skin color appropriate for ethnicity except facial rash which is red
HEENT:
Head: Normocephalic and atraumatic without tenderness or palpable masses. No scarring noted. Hair is evenly
distributed.
Eyes: PERRLA, Conjunctivae are clear bilaterally without exudate, EOM intact
Right Ear: Auricle well-formed and aligned bilaterally; mastoid process non tender to palpation. No impacted
cerumen. External auditory canal is clear. Tympanic membrane intact, pearly, shiny gray with appropriate light
reflex. No perforation, erythema or drainage noted.
Left Ear: Auricle well-formed and aligned bilaterally; mastoid process non tender to palpation. No impacted
cerumen. External auditory canal is clear. Tympanic membrane intact, pearly, shiny gray with appropriate light
reflex. No perforation, erythema or drainage noted.
Nose: Nasal Mucosa is pink and moist; Septum is midline and nares patent bilaterally.
Mouth/throat: Mucous membranes are pink and moist. Tongue -Negative for lesions and Symmetrical
movement noted. Good dentition noted without odor. Trachea midline
Pharynx: Oropharynx is clear. No tonsillar swelling or exudates. No oropharyngeal exudate. Uvula Midline
Neck: Supple- No carotid Bruits, no visible JVD- Thyroid examined from posterior position; gland non-enlarged,
smooth, and mobile with swallowing.
Lymphatics: No Lymphadenopathy palpated on submandibular, submental, occipital, anterior and posterior
cervical chain or supraclavicular-
Thoracic: symmetrical chest rise- No chest wall tenderness
Lungs: Pulmonary effort easy- Clear to auscultation in all lung fields
Heart: Regular rate and rhythm. No murmurs, rubs, or gallops noted. S1 and S2 auscultation clear. PMI at 5th
ICS, midclavicular line, not displaced. No jugular venous distention (JVD). Peripheral pulses 2+ and equal
bilaterally.
Breast: deferred
Abdomen: Abdomen soft and non-tender on palpation. No guarding. Bowel sounds are normoactive x4.
Negative CVAT bilaterally.
Genitourinary (male): deferred Rectal: Deferred Extremities: Cap refill <3 seconds on fingers and toes, full active ROM x4 extremities, steady without assistive devices, no edema noted on bilaterally upper extremities. LLE free of swelling, Minimal swelling in RLE. No erythema, warmth, or drainage observed in LLE- RLE wound wrapped, dressing managed weekly by outpatient wound clinic. No odor or saturation through dressing noted. Pulses intact (DP/PT 2+ bilaterally Neurologic: No focal deficit, Alert and Oriented X4. Sensation intact to light touch, 5/5 strength noted in upper and lower extremities, no Gait abnormalities. Psychiatric: Mood and affect appropriate to situation, pt cooperative, appropriate judgement, no evidence of hallucinations- Pt does not appear depressed, anxious, or agitated on exam Labs and Diagnostic Studies: None in office ASSESSMENT: Differential Diagnosis:
1. Most Likely Diagnosis- ** Rosacea - Dx-ICD-10 Code (L71.9)
The least likely diagnosis for this patient is seborrheic dermatitis. In this condition, facial lesions typically favor the forehead and nasolabial folds and may resemble a malar, or “butterfly,” rash. However, seborrheic dermatitis usually involves additional areas such as the scalp and trunk. While the patient reports pruritus, the rash is not scaly, which is a characteristic feature of seborrheic dermatitis. Dry, patchy areas and dandruff of the scalp are also common in this condition, but these findings are absent in this case.
Actual diagnosis: Rosacea - Dx-ICD-10 Code (L71.9)
PLAN:
DIAGNOSIS- Rosacea Laboratory and Diagnostic Tests: ANA, Sed Rate, comp activity ( rash +family history of lupus )- TSH,A1C, Lipid, CMP,CBC/diff ( establishing baseline- new pt.) Pharmacology/Medications: -Start: Rx Losartan _(Cozaar) 50mg
Sig: 1 tablet (PO) Once daily No refills_ -Start : Rx Metronidazole (Metrogel) 0.75% #70 g Sig: Apply topically to face 2x daily No refills Non-Pharmacology:
- Moisturize facial skin daily with emollients as they help to repair and maintain barrier function.
- Cleanse your face at least once per day with non-soap cleansers and lukewarm water
- Be sure to apply broad spectrum sunscreen with at least 30 SPF daily. (Maier, Rosacea: Overview of treatment,
Consults / Referrals: Referral sent to Dermatology and general surgery for colon screening Patient education:
- Be sure to wash hands before touching face and/or applying topical medication
- Apply your topical medication 2x daily as prescribed. The most common side effects of metronidazole are local irritation, dryness, and stinging (Maier, Rosacea: Treatment of papulopustular features in adults, 2025). Please reach out with other symptoms
- Be sure to avoid possible triggers such as sunlight/hot temperatures, spicy foods, and alcohol.
- Continue taking Losartan as before- Please avoid running out of this medication in the future as serious problems may arise. Check your BP at least once a day at home to ensure results. Please all the office with any questions.
- You have received your TDAP and FLU vaccine today- Please reference your handouts for possible side effects. Feel free to call the office if there are any issues.
- Elevate your legs when you are sitting or lying down. Follow-up: -Referral has been placed to dermatology- please make appt if rash does not improve. -Please continue to f/u with journey recovery once monthly as directed.
- Please continue to f/u with DBN wound clinic weekly as directed
- Please make pcp office appt for 3 mths to f/u on medications and any questions/concerns you may have. -Please plan to follow all education points for an effective healing process ==================================================================================== Health Maintenance Recommendation: Colon Cancer Screening is due now- Can schedule with general surgery when they reach out Tdap received today- next 9/18/ Flu received today- next 9/1/ Annual wellness 9/18/ Schedule regular dental and vision check ups Practice healthy diet and exercise
References
