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7. Medications: The patient utilised topical creams and ointments including daivonex
50mcg/g cream, daiobet 50/500mcg/g ointment, diprosone 0.5mg/g cream, and Enstilar
50mcg/500mcg per 1g foam spray during the past 18 years. The systemic treatment
includes methotrexate 10mg/week, cyclosporin >2mg/kg/day, neotigason/acitretin
>0.4mg/kg. The patient also received ultraviolet therapy three times per week, that he
could not continue based on the reported occurrence of burning sensation.
8. Habits: The patient does not effectively comply with the recommended
pharmacotherapeutic regimen. The patient is a homosexual male.
9. Sleep patterns: The patient continues to experience sleep disturbance under the impact of
sustained itching due to psoriasis (Czarnecka-Operacz et al., 2015).
10. Exercise habits/ health maintenance: The patient minimally engages himself in exercise
and physical activity.
11. Last menstrual period or date of menopause: Not applicable.
12. Education / cultural: The patient renders services on the profile of a musical supervisor
and also pays the organ inside a Church at Grafton.
Review of Systems:
A. General: NAD (No Abnormality Diagnosed).
B. Skin: Red, scaly and itchy rashes widely spread over upper trunk, limbs, and scalp despite
receiving systemic treatment for psoriasis.
C. Head/face/sinuses: No sinus complication and headache.
D. Eyes: No redness and pain; normal vision.
E. Ears: No vertigo or earache; normal hearing status.
F. Nose: No nasal bleeding or stiffness.
G. Mouth/throat: No sore tongue, hoarseness, or bleeding gums.
Master of Nursing: Patient Assessment 3

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SOAP Documentation for Patient with Psoriasis

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