NRNP 6531 Week 2 Assignment; I Human Case Study - Evaluating and Managing Integumentary Conditions
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FOCUSED SOAP NOTE-Daisie Blankenship I human Allergic Contact Dermatitis CC: "I have this ugly looking rash on my upper thighs"
HPI: Patient is a 25 y/o female presenting with an itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash.
PMHx: Denies Hospitalizations: None Family History:
Maternal grandfather died of CVD at age 81.
Grandmother (age 88) has prior heart attack, stent and HTN. Mother alive and well. Father alive and well, treated for HTN. Brothers - 35 and 32 both alive and well. Sister - 21 alive and well. SHx
Tobacco: Denies ETOH: Socially Illicit Drugs: Denies
Occupation: English teacher for 7th and 8th grade
Relationship: Sexually active heterosexual female in a monogamous relationship Diet: Normal American Diet Reproductive
Hx Age of menarche: "doesn't remember." Menstruation cycle duration: "seems fine to me," regular periods.
Sexual hx and concerns: Denies concerns LMP: unknown Breast screening: Conducts self-breast exams
Last Pap Smear: 1 year ago, with no signs of abnormalities Gravida para status/Childbirth hx: Nulliparous
Allergies: Ceclor (Cefaclor) second generation cephalosporin - Patient developed hives as child when taking this antibiotic for otitis media
List of Current Medications: Birth control pill Review of Systems: (ROS)
General: pleasant Caucasian female. A/O X4……….. Continue
