Comprehensive SOAP: Advanced Health Assessment

Comprehensive SOAP Patient Initials: _______Age: _______Gender: _______ SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): Increased appearance of dark red spots on right forearm for the 6 days (graphic no.1) History of Present Illness (HPI): Andrew James is a 65-year-old Caucasian male complained of a general flat, easy bruising, thin skin on his left forearm for several months. He noticed this when he observed that he had at about 1 centimeter by 1 centimeter irregularly shaped dark red patches on his left forearm. He added multiple occurrences of tearing his left forearm's skin with minimal trauma and repeated bruising. He reported that he was a truck driver for 25 years where he additionally stated that his left arm was exposed to the heat of the sun for his years of road signaling as he drove massive vehicles. He revealed taking up multivitamins and aspirin to treat minor body aches and no other medications for any systemic illnesses. He tried to use moisturizing cream on the dark spots, but noticed “no improvements”. Andrew reported that there is no pain at the areas with dark spots. 1 Location: left forearm 2 Quality: small dark spots 3 Quantity or severity: multiple spots but not painful 4 Timing, including onset, duration, and frequency: chronic 5 Setting in which it occurs: unknown 6 Factors that have aggravated or relieved the symptom: moisturizing cream not helpful 7 Associated manifestations: Flat thin easy bruising skin Medications: Over the counter multivitamins and aspirin Allergies: No known drug or food allergies Past Medical History (PMH): 1 Facial trauma in Vehicular accident (1993) 2 Appendicitis (2008) Past Surgical History (PSH): 1 Oral and maxillofacial surgery (1993) 2 Appendectomy (2008) Sexual/Reproductive History: Heterosexual Sexually inactive Personal/Social History: The patient denies smoking. The patient consumes 1 beer per day. Patient denies illicit drug use. Immunization History: The patient’s immunizations are up to date. He received the flu vaccine on January earlier this year. Significant Family History: Two Brothers- one with papilloma and a history of eczema at age 60 while the other one, age 67, has a history of psoriasis and hyperplasia of the sebaceous glands. She has one daughter, age 37, has linear lesions. Lifestyle: The patient retired from his truck driving job to focus on their family's agricultural land. He and his brothers manage the planting and harvesting of the crops on different seasons of the year. He has a healthy diet and eating pattern. He has a good support system composed of family and friends. Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text. General: The patient is apparently healthy. No fever, chills or night sweats. The patient denies pruritis. No significant weight gain ...