lOMoAR cPSD| 11700591
lOMoAR cPSD| 11700591
Health Assessment Skin Condition SOAP NOTE Differential Diagnosis for Skin Conditions Skin Condition Picture # 5
Patient Initials: Gender: F
AJ
Age:
24
SUBJECTIVE DATA: Chief Complaint (CC): Painful rash and joint pain History of Present Illness (HPI): Anna James is a 24-year-old Caucasian female who presents today with a new onset of a painful plaque-like rash and joint pain 3 weeks ago. She reports she first noticed the rash on her knees and it has now developed on her elbows and scalp. She also reports that the rash is sore and slightly itchy. Anna has also noticed achy joints as well throughout the last 3 weeks. She reports that stressful situations seem to exacerbate the issue. She has changed laundry detergent and noticed no improvements in the rash, and she has also been taking Ibuprofen 400mg 3 times a day most days with little relief in pain. Anna reports the severity of her rash and joint pain to be 6/10. Medications: 1 Over-the-Counter Ibuprofen 400mg PO every 6 hours as needed 2 Women’s Multivitamin 1 tablet PO daily