Nursing -soap note

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SOAP Note on Eczema

Name xxx

United State University

Primary Healthcare of Chronic Clients/Families Across the Lifespan-Clinical Practicum

xxx

Professors xxxx

Date xxx

SOAP Note on Eczema

ID: Mr., Client’s Initial: G.G, Age: 65, Gender: Male, Race: Native American, Date of Birth: January 01, 1957,

Marital Status: Married.

Subjective Data

CC: “I have inflamed and cracked skin patches.”

HPI: Mr. G.G., a 65-year-old Native American male, was accompanied his wife to the hospital having inflamed and cracked skin patches. The symptoms are clearly visible on parts of the hands, around the eyes, and parts of the neck. He reported that the symptoms were visible six days ago. The skin of the patient is very sensitive and too dry. However, he states that he has not received any treatment for his condition. There were some swellings on parts of the elbows and right cheek. He also reported that he cannot perform heavy tasks as a result of his conditions. He has had a history of blood pressure and diabetes six years ago. Four years ago, he has a problem with nose bleeding but it was treated. He has no any kind of allergies known. He has been currently taking Metformin 750mg once per day for diabetes management.

Past Medical Records: He has never had a serious acute or chronic illness; however, he has had moderate flu in the past, which he was able to treat with home remedies like ginger. He’d never been in a hospital before.

Surgeries: No past medical surgery.

Family History: The patient is married to one wife and together they have three children. His first-born daughter, 27 years old, is shortsighted and uses lenses for proper vision. His second born daughter, 24 years old and last-born son, 20 years old, are both healthy. His wife, 56 years old, is a retired senior schoolteacher and was diagnosed with arthritis at the age of 40 and she is currently under medication. His mother passed away at 80 years old due to brain cancer complications. His father, 90 years old, is still alive and on medication for diabetes type II. Both his grandparents are diseased of heart attack.

Social History: Mr. GG is a retired military officer, he retired 1 year ago. He lives with his father, wife and his three children in the same household. His children are all in school. No one in the household smokes cigarettes nor drinking alcohol. He spends most of the time watching documentaries, feeding his rabbits and golfing. On weekends, he visits his friends and goes to church on Sundays with other members of the family. He has not travelled recently nor has he interacted with sick people. He always maintains a healthy diet. He has three pets, two dogs and one cat.

Review of Systems

Constitutional: Mr. G.G. he claims that he is neither unwell nor ailing from a fever or chills. He also hasn’t gained or lost weight for the past few months.

Head: The patients confirms he has had no headaches, numbness or loss of consciousness.

Eyes: The patient denied any cases of blurred vision. He states that his light perception is good and he denies any eye defect. However, he has some inflammations and cracked skin patches around the eyes, and the skin around the right eye is so dry.

Neck: There are some inflammations and cracked skin patches on the left and backside of the neck. However, he does not have any bruits or meningeal symptoms.

Ears: He denies any cases of discharging coming out from the ears. He stated that he has never lost his sound perception ability over the years.

Nose: He doesn’t have runny nose or a stuffy nose, nor does he have erythema or inflammation in his nasal passages, nor does he have nosebleeds. He is also free of discomfort and has a characteristic odor.

Mouth: He doesn’t have any oral growths, gum disease, parched lips, sores, ulcers, tooth disease, oral discomfort, or a tongue tumor. The taste is typical.

Throat: He does not have a throat infection and has no difficulty swallowing solid foods.

Skin, Hair, and Nails: The skin of the patient is scaly, itchy on parts of the hands, neck and around the eyes. There are also some swellings on parts of the elbows and right cheek. He has no abnormalities in hair color.

Cardiovascular: He doesn’t have any palpitations. He doesn’t have any chest aches, coughing, breathing difficulty, or trouble making deep breathing exercises. He also has no tightness in his chest. He doesn’t have any heart murmurs, dyspnea, breathlessness, or profuse sweating.

Gastrointestinal: He has no nausea or vomiting, no constipation or diarrhea, no decreased appetite, no gastrointestinal ulcers or gastritis, no abdominal cramps or inflammatory diseases, no dysphagia, and no hematochezia.

Genitourinary: He has never experienced any burning sensation during urination. He stated that he has no urinary complications.

Musculoskeletal: He has no joint problems, however he has some elbow swelling, and no injuries, no muscle aches, no disk malfunction, no backaches, no gout, and all of his parts of the body operate properly.

Neurological: He hasn’t had any migraines, head injuries, epilepsy, or brain tumors, and he hasn’t lost any memory. He has no fainting spells, insanity, tremors, or paralysis.

Psychiatric: The patient stated that he has never thought of committing suicide. He denies any cases of sleeping difficulties, anxiety, and depression

Allergies: He doesn’t have any known medication or food allergies, and he isn’t intolerant to animal fur.

Objective Data

Vital Signs

Temperature: 88 F, Height: 6fts, Weight: 167lbs, BP: 120/76, RR: 17 breaths per minute, SpO2: 99%, BMI: 28.5 kg/m2.

Physical Examination

Constitutional: He is pleasant to be around, appears to be in good condition, and is observant.

Head: He has a normal head shape. His hair is thick and evenly distributed across the top of his head.

Eyes: He has no inflammation in his eyes, and his cornea is perfectly clean. He has excellent vision. To get clean eyesight, he does not use eye glasses.

Ears: He has no inflammations and no hearing problems, according to his assessment.

Nose: There is no nasal secretion, inflammations, sinus distortion, or splenic pain in him.

Mouth: He has no gum disease, no lip sores, and no swellings or lesions on his tongue. The dental formula is within typical limits. When examined attentively, though, his lips seemed blue. In the oropharynx, he shows neither erythema nor discharge. Moisture is present in mucosal membranes. Furthermore, the tonsils are of normal size.

He exhibits erythema and a wet oropharynx, as well as white exudate on his tongue. Bilaterally, the tonsils are separated into four quadrants.

Neck: There are no malignancies in the trachea, which is placed in the center. In the neck, neither cervical nor axillary lymph nodes, nor supraclavicular lymph nodes, may be observed. The thyroid glands have no nodules or hyperplasia.

Lungs: After a cough, the breath sounds regular, with little wheezes. There is no breathlessness.

Cardiovascular: There have been no chest noises, chest pain, or palpitations found. S1 and S2 were found to be present. Respiratory activity that is both easy and consistent. Coughing and wheeze were present. There were no hiccups.

Abdomen: The abdomen is nontender, soft, and all four quadrants have bowel sounds.

There was no organomegaly to be found.

Musculoskeletal: The motors’ strength and tone are normal. There is no cyanosis in the extremities.

Neurologic: He hasn’t had any migraines, head injuries, seizures, or brain infections, and he hasn’t lost any memory. He does have fainting spells, epilepsy, tremors, and paralysis.

Skin: The skin of the patient has patches that are scaly, itchy and inflamed. The skin also has some swellings.

Psychiatric: His decision-making skills are remarkable. He has a typical mood and attitude, and he is active and aware. Memory recall is great in both the present and the past.

Assessment

Primary Differential Diagnosis

1. Eczema L20-L30 – This disease is termed atopic dermatitis. This disease is characterized by inflamed and scaly skin patches. The skin is also very rough and if there is severe itches blood may come out of the skin patches. For people who have white skin, they may have some red patches (Nazarko, 2020). It also makes one’s skin have some swellings. A skin biopsy test is necessary for the diagnosis of this disease. The patient presents the symptoms associated with this disease and he is suffering from eczema (Nazarko, 2020).This confirms eczema as the primary diagnosis.

2. Scabies B86 – When small bugs called mites burrow through into top layer of the epidermis and lay eggs, you have this infectious illness (Raffi et al., 2019). The disease also makes one have vesicles on the skin. This disease mostly affects the groins, wrists, ankles, and palms. Scaly spots, similar to eczema, are possible. Unlike eczema, scabies itching tends to worsen at night (Raffi et al., 2019). On portions of your skin where the mites burrow, you may also see a few small elevated and crooked lines that appear gray-white or flesh-colored. According to the symptoms presented by the patient this disease is ruled out.

3. Seborrheic dermatitis L21. 9 – This disease mostly affects the cheeks. Seborrheic dermatitis often results in redness, swelling, and greasy scaling (Wikramanayake et al., 2019). Seborrheic dermatitis can also affect oily areas of the body, such as the face, sides of the nose, eyebrows, ears, eyelids and chest. The symptoms of this disease do not comply with the symptoms presented thus eliminating the disease.

Diagnostic Plan

Culture skin lesion- This is to determine viral, bacterial, or fungal etiology (Cash et al, 2017).

Blood tests- The serum immunoglobulin E (IgE) is elevated with atopic dermatitis including eczema (Cash et al, 2017).

Allergy skin testing- may be considered

Skin Biopsy Test-A skin biopsy is a procedure in which cells or skin samples are removed from your body and tested in a laboratory.to rule out other skin diseases from atopic dermatitis, such as low-grade skin cancer or psoriasis (Salvador et al., 2020).

Treatment

Medication: Topical calcineurin inhibitors, bandages, and therapeutic clothing may be used to treat all kinds of eczema in older persons. External moisturizers should be used as a first-line therapy for elderly eczema patients who have dry skin (Salvador et al., 2020). Epimax plus cream, Cerave moisturizing cream, and Cetaphil moisturizing cream are among them. Antihistamines are commonly used as an adjuvant therapy for anti-inflammatory medications and moisturizers applied topically (Salvador et al., 2020). For moderate-to-severe instances of geriatric eczema, oral corticosteroids taken in modest dosages (5–15 mg/day or 0.1–0.2 mg/kg body weight/day in prednisolone-equivalents) and with careful attention to side effects may be beneficial (Salvador et al., 2020). At a dosage of around 3 mg/kg/day, oral cyclosporine is useful in treating severe instances of senior eczema. For elderly people with eczema disease, oral cyclosporine should be used (Salvador et al., 2020).

Home Remedies: Bathing on a daily basis is necessary for eczema sufferers because it keeps the skin moisturized and prevents infection (Eichenfield et al., 2021). Strong soaps and detergents, as well as products containing aromas, colors, or perfumes, should be avoided. When washing, the patient should likewise avoid scrubbing his skin for too long (Eichenfield et al., 2021).

Education: The patient will be educated on the importance of keeping his skin moist. This is in the management of the disease (Eichenfield et al., 2021). He is also educated on how to use natural products such as coconut oil, sunflower oil and cardiospermum to relieve itchiness. Allergens such as dust in mattresses, carpets, and rugs should be avoided by the patient. The patient should avoid wearing wool or other scratchy materials. (Eichenfield et al., 2021).

Follow up: the patient should revisit the hospital after one week to examine the skin treatment.

Referral: If the skin eruptions are severe or don’t respond to conservative treatment, refer the patient to a dermatologist.

References

Cash, J., & Glass, C (2017). Family practice quideline (4th ed.). Springer Publishing Company, LLC.

Eichenfield, L. F., Kusari, A., Han, A. M., Barbarot, S., Deleuran, M., Lio, P., … & Stalder, J. F. (2021). Therapeutic education in atopic dermatitis: A position paper from the International Eczema Council. JAAD international, 3, 8-13.

Nazarko, L. (2020). Eczema and the older person. British Journal of Community Nursing, 25(9), 451-459.

Raffi, J., Suresh, R., & Butler, D. C. (2019). Review of scabies in the elderly. Dermatology and Therapy, 9(4), 623-630.

Salvador, J. S., Mendaza, F. H., Garcés, M. H., Palacios-Martínez, D., Camacho, R. S., Sanz, R. S., … & Giménez-Arnau, A. M. (2020). Guidelines for the diagnosis, treatment, and prevention of hand eczema. Actas Dermo-Sifiliográficas (English Edition), 111(1), 26-40Wikramanayake, T. C., Borda, L. J., Miteva, M., & Paus, R. (2019). Seborrheic dermatitis—looking beyond Malassezia. Experimental dermatology, 28(9), 991-1001.

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