Skin, Hair, and Nails SOAP Note Example

Below is a nursing SOAP note for a skin, hair, and nails examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

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• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Cardiovascular SOAP Note Example
• Abdominal SOAP Note Example
• Musculoskeletal SOAP Note Example
• Neurological SOAP Note Example
• Discharge SOAP Note Example

Subjective:

1. Chief Complaint: Patient reports a rash, itching, and brittle nails.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started approximately two weeks ago.
   • Location: The patient reports the presence of the rash on their arms, legs, and trunk. The itching is generalized.
   • Duration: The patient mentions that the symptoms have been persistent since their onset.
   • Character: The patient describes the rash as red, raised bumps that become more pronounced with scratching. They report intense itching, especially at night. The nails are brittle and prone to breaking.
   • Aggravating Factors: The patient reports that the itching worsens at night or after exposure to certain fabrics or substances.
   • Relieving Factors: The patient states that applying cold compresses and using over-the-counter antihistamines provide temporary relief for the itching.
   • Treatment/Interventions Tried: The patient has been using over-the-counter hydrocortisone cream on the rash and taking antihistamines for symptom relief.
3. Past Medical History: Document any relevant past medical conditions, allergies, or dermatological disorders that may be related to the current symptoms. Include details about any previous skin conditions or known sensitivities.
4. Allergy History: Inquire about any known allergies to medications, topical products, or specific substances that may cause skin reactions. Note the type of reaction experienced and any known allergens to avoid.
5. Medication History: Record the patient’s current and past medication history, including prescribed medications, over-the-counter remedies, or topical treatments used for skin conditions or allergies.
6. Social History: Explore the patient’s occupation, hobbies, and any recent changes in environment or exposure to potential allergens or irritants. Assess any history of exposure to chemicals, harsh detergents, or frequent handwashing.
7. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the skin, hair, and nails. Inquire about associated symptoms such as dryness, scaling, hair loss, or changes in the nail color or texture.

Objective:

1. General Appearance: The patient appears uncomfortable, with visible red, raised bumps on the arms, legs, and trunk. The nails appear brittle and exhibit signs of irregular ridges and breakage.
2. Skin Examination: Inspect the rash, noting the distribution, texture, color, and any signs of inflammation. Observe for signs of scratching, excoriation, or secondary skin infections.
3. Hair Examination: Assess the hair texture, density, and presence of any hair loss or scalp abnormalities.
4. Nail Examination: Inspect the nails for color changes, deformities, brittleness, or signs of infection.

Assessment:

1. Medical Diagnosis: Contact dermatitis with associated pruritus and brittle nails.
2. Problem Identification: Patient reports rash, itching, and brittle nails.
3. Relevant Findings and Abnormalities: Red, raised bumps on the arms, legs, and trunk; intense itching; brittle nails with irregular ridges.
4. Client Education Needs: Patient requires education on managing contact dermatitis, itch relief measures, nail care, and the importance of follow-up appointments.

Plan:

1. Medical Interventions:
   • Recommend avoiding known triggers and irritants, such as specific fabrics or substances.
   • Prescribe a topical corticosteroid cream or ointment for the rash and itching.
   • Discuss the use of emollients or moisturizers to alleviate dryness and maintain skin hydration.
2. Patient Education:
   • Educate the patient about common contact dermatitis triggers and the importance of avoiding them.
   • Instruct the patient on proper skincare techniques, including gentle cleansing and moisturizing.
   • Provide information on the use of antihistamines for itch relief and precautions to prevent secondary skin infections.
3. Referrals or Consultations:
   • Consider a referral to a dermatologist for further evaluation and specialized treatment options.
   • Schedule a consultation with a nail specialist for nail care recommendations and potential treatments for brittle nails.
4. Safety Measures:
   • Assess the patient’s home and work environment for potential irritants and provide recommendations for minimizing exposure.
   • Educate the patient on when to seek immediate medical attention for worsening symptoms or signs of infection.
5. Evaluation:
   • Schedule a follow-up appointment in two weeks to assess symptom improvement, evaluate treatment effectiveness, and make any necessary adjustments to the management plan.
   • Monitor for any signs of worsening symptoms, secondary infections, or nail abnormalities.

• This example demonstrates a skin, hair, and nails SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes general appearance, skin, hair, and nail examinations.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification.
• The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.