Alternative Medicine and Nursing Assignment

Abstract

There is a proper diagnosis Soap assessment whose history is given. The data will be analyzed of part A: Skin, Hair, and Nail assessment and part B: Nose, Mouth, and Throat assessment respectively. Then according to the Soap format, the proper diagnosis will be conducted and the assessment will then be finalized according to it.

Introduction: Female, age 48, home setting, housewife.

Part A: Skin, Hair, and Nail Assessment

Subjective Information

Skin. There is no previous history regarding any skin disease. The skin color or pigmentation history of patient is described as mole beneath the right eye on the cheek. The mole has also been detected on the left side above the eye. Excessive dryness or moisture is not recorded and so do the skin etching. Excess bruising was also found on the right arm bicep. There is rash or lesions out there. The patient was using Levothyroxine as the medicine that was prescribed to her. No hair loss or change in nails has been recorded. There was also no environmental hazards found on the skin. The prescribed skin care lotions and sunscreen was anything that moisturizes the skin, specially SPF 30 sunscreen. She was also advised to avoid sun rays and stay in shade as much as possible.

Objective information

The physical examination included color, pigmentation, temperature, moisture, texture, edema, mobility/turgor, vascularity/bruising and lesions. The color was tan due to the sun rays. Freckles on the shoulder and face was also recorded. The temperature was warm or equal to +10. Moisture was WNL and Texture was smooth as ever. Thickness was uniform and pedicure was just done before 2 weeks. There was no edema, but mobility and turgor was recorded. The mobility is WNL and turgor is elastic; reddened area. Regarding the inspection and palpate hair, the color is brown. The ...