Holistic Health

In: Other Topics

Submitted By rbutter
Words 10563
Pages 43
Holistic Health Assessment: SOAP Paper

Roxie Butterfield

University of Texas at Arlington

Assessment of BB

BB appears to be a healthy 63 year old male. He is neatly groomed and dressed. He is

5”10 and weighs 220 lbs. His BMI is 29.04.

Subjective Data

Skin, hair, and nails:

BB states he has no skin rashes or lesions. He does, however, state that he has very dry skin. Patient states that he has no bruising, swelling, or pigmentation problems. His main concern today is a large raised mole on his shoulder.

C: light brown dry raised mole. “I think about 1/2” in length.”

O: “It has been there for a long time.”

L: “It is on my right shoulder, you can't miss it. I don't have anything like it on my body.”

D: “It doesn't go away and I haven't noticed that it has changed in size or color.”

S: “It doesn't really bother me but I have heard I should have it check out.”

P: “There isn't anything that makes it feel better or worse, because it doesn't hurt at all.”

A: “I am afraid that I might scrape it when I am putting my shirt on and off. It bothers my wife more than it does me.”

BB denies having any other moles that he is concerned with. BB states that he hasn't had any other skin issues such as itching, pain, tingling or redness. BB does think that his skin is somewhat dry. BB states that he has had no skin problems other than a sunburn once in a while. He doesn't know of any allergies or skin reactions other than the normal skin reactions such as poison ivy. BB states that he doesn't notice any significant hair loss. He has not noticed any changes in his nails or nail beds. BB denies any issues with body odor.

Past History:

BB states that he has never had neck or head injuries. He has never had surgery on his…...

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