NURS 6512N

Advanced Health Assessment

Walden University

Week 4Assignment

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SOAP NOTE

Differential Diagnosis for Skin Condition

Skin Condition Picture #5

Patient Initials: AP Age: 69 Gender: M

SUBJECTIVE DATA:

Chief Complaint (CC): Complains of rash that have some blisters and scab on the chest and

back.

History of Present Illness (HPI): Mike Jones is a 69-years old Caucasian male who presents today with a new onset of clusters of rash and blisters on his anterior, right flank and posterior chest. He reports that 4 days prior to the rash appearing he had itching, tingling, burning and pain in the same area of the rash. He reports the severity of pain 7/10 and 10/10 with palpation.

Medications:

1. Tamsulosin (Flomax) 0.4 mg for BPH

2. Over the counter Aspirin 81 mg daily

3. Over the counter Benadryl 25mg 1 tab every 6 hours for itching.

4. Over-the-counter topical hydrocortisone cream for itching as needed.

5. Over-the-counter Tylenol extra strength two tablets every 6 hours for pain.

Allergies: No Know Drug Allergies

Past Medical History (PMH):

1. Benign prostatic hyperplasia – age 50

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2. History of gallstone- age 45

3. Chickenpox – age 6

4. Chlamydia-age 25

Past Surgical History (PSH):

1. Cholecystectomy 2010-age 59

2. Transurethral resection of the prostate 2012 – age 61

Sexual/Reproductive History:

Heterosexual

Personal/Social History: Past tobacco product use, quit more than 30 years ago, denies ETOH,

or illicit drug use. He enjoys fishing and camping with his friends and visiting with his children

and grandchildren as often as he can. He drinks an occasional glass of wine or beer at social

gathering.

Immunization History: His immunizations are up to date. Patient last Influenza vaccine was

two weeks ago. Received the pneumococcal vaccine at age 65. Believe all childhood vaccination

was received. Last Tdap received when he was in college.

Significant Family History:

Natural death- Mother-deceased at age 90.

Gout, hemorrhagic stroke, hypertension, ETOH -Dad age 92.

Cervical Cancer- Maternal grandmother died at age 86.

Congestive heart failure, Asthma, COPD – Maternal grandfather- die at age 75.

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Drown-Paternal grandmother – deceased at age 35 in a boating accident.

Stroke, Hypertension – Paternal grandfather, deceased, at age 70.

Lifestyle

Patient is married to his wife of 30 years with two adult children and 3 grandchildren. He owns a

business that sell different insurance product. He in the process of handing the business over to

his two children who current work with him to retire next year. The patient is petty active both

him and his wife walk at least for an hour three to four times a week.

Review of Systems:

General: Patient denies fever, fatigue, or poor appetite. Endorse severe pain at the site of the

rash.

HEENT: Denies any head injury or headaches, blurred vision or floaters. Does yearly eye exam,

appointment coming up in three months. History of astigmatism but had Lasik surgery10 years

ago. Negative for hearing loss, tinnitus, or ear pain. Have issue with excessive wax for which he

sees an ENT specialist for cleaning one a year. Last cleaning was two months ago. Denies any

issue or history of nose- bleed, post-nasal drip, congestion or change in smell or recent cold.

Patient denies any dry mouth, throat soreness, cough or history of strep throat. Patient had dental

implant done two years ago.

Neck: No complaints of pain or discomfort, no swollen lymph nodes. No jugular veins

distention.

Breast: Denies tenderness/discomfort. No drainage or gynecomastia.

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Respiratory: No shortness of breath, cough, or congestions. Denies chest pain or discomfort.

No environmental exposure, no exposure to second- hand smoking. No history of pneumonia or

tuberculosis.

CV: No complaints of chest pain, palpitation or dyspnea on exertion. No edema, history of

syncope, rheumatic, claudication or thrombophlebitis. Negative for hypertension or abnormal

electrocardiogram

GI: Denies any nausea, vomiting, diarrhea , constipation, change in appetite, bowel pattern

every three days. No history of hemorrhoid, rectal bleeding, food intolerance or indigestion.

Patient has a history of gallbladder disease.

GU: no dysuria, penile pain or discharge, hematuria, no testicular pain, history of urinary tract

disease or hernias. Patient has history dribbling after urination, nocturia, frequent urination, sense of

incomplete bladder emptying, urinary urgency to urinate and a weak urinary stream. Abnormal

ejaculatory patterns. No history of STDs.

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 1

Abstract Objective: This study aimed to explore hypertensive patients’ perspectives on quality use of medication and issues related to hypertension management at the community level in Malaysia. Methods: Focus groups discussion was employed in this qualitative study. A total of 17 hypertensive patients were purposively recruited. Three focus group discussions with semi-structured interview were carried out at Flat Desa Wawasan, Penang. All the conversations were audio recorded, transcribed verbatim and thematically analysed. Results: Three major themes were developed, including medication adherence among hypertensive patients, self-management of hypertension and patients’ knowledge towards hypertension. Poor medication adherence was found and different strategies were taken to overcome the barriers towards adherence. Use of herbal and traditional therapies was perceived as alternative method in controlling blood pressure instead of taking antihypertensive medication. The participants were found to have poor knowledge on side effect and mechanism of action of hypertensive medication. Conclusions: The misconception about the side effect of antihypertensive medication has led to poor adherence among the participants. Lack of knowledge on targeted blood pressure level has led to poor blood pressure monitoring among the participants. Health awareness program and counselling from health care professional should be advocated among the hypertensive patients in addressing the above gaps.

Keywords Hypertension; Medication Adherence; Patient Medication Knowledge; Health Knowledge, Attitudes, Practice; Focus Groups; Qualitative Research; Malaysia

INTRODUCTION

Hypertension is one of the renowned risk factors contributing to cardiovascular disease, including stroke, arrhythmias, coronary heart disease and myocardial infarction.

1 About 1.39 billion adults worldwide were

diagnosed with hypertension 2 in 2010 and the number is

predicted to increase to 1.56 billion by year 2025. 3 More

than half of the hypertensive patients were unable to achieve well-controlled blood pressure level despite the recent advancement in the antihypertensive treatment.

4

Poor medication adherence is one of the contributing factors that caused uncontrolled blood pressure level among hypertensive patients.

5-7 The rate of medication

adherence in many developing countries including Malaysia was reported lower when compared to developed countries.

8-11

Likewise, in 2015, 30.3% of the Malaysian adults (i.e. 18 years and above) had hypertension, with 13.1% of known hypertension and 17.2% of undiagnosed hypertension.

12 Of

note, only 26.8% of these hypertensive patients had their blood pressure under control

13 and up to 46.6% of them

were reported to have poor medication adherence. 14

A recent local study revealed that a total of 20,799 excessive pills were returned by hypertensive patients at a single Malaysian government hospital, with a total cost of (Malaysian Ringgit) MYR 4,362.28 (equal to USD 1037) was wasted during the 8 months of study period with an average wastage of MYR 42.35 (equal to USD 10) per patient; changing medication by the doctor and death of patients were the most common reasons accounted for the wastage.

15

Low rate of adherence to antihypertensive medication has significantly increased blood pressure and was associated with higher rate of hospitalization and mortality.

16 Previous

studies have found that many hypertensive patients did not adhere to antihypertensive medication because they had wrong perception towards hypertension or they were unconfident with their antihypertensive medication such as concern of potential adverse effects.