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NSG 6020 Soap Note – Linear Vesicular Rash
NSG 6020 Soap Note – Linear Vesicular Rash
Episodic SOAP Note Sample Note:
For purposes of this sample SOAP note comments on what is required for each section have been left in place. You would not leave these in an official SOAP note. Name: K. P. Date: 09/03/2014 Time: 0800 Age: 34 Sex: Male
SUBJECTIVE
CC:
“I have a burning red rash on my back.” Reason given by the patient for seeking medical care “in quotes”
HPI:
34 year old male presents to office with a linear vesicular rash to the right side of his back. Patient states he began to feel a tingling and burning sensation to the area approximately 48 hours age, and then blisters appeared 24 hours ago.
Patients states he now feels a constant sharp, burning pain in the area. He states the patin is often as 8 or 10 out of 10 severity. He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. The pain worsens with touch and movement. Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. Patient reports having chicken pox when he was age 5.
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) Benicar 10 mg PO daily for HTN
PMH Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas:
Patient has a significant history for hypertension
Chronic Health Problems: 1. HTN (401.1) – controlled
Hospitalizations/Surgeries: None
Other: Immunizations: Up to date on all immunizations. Flu shot in October 2012 and plans to get the Flu vaccine this year. Tetanus booster vaccine in 2010.
Environmental hazards: Patient denies any environmental hazards.
Safety meaures: Patient states “I always wear my seatbelt”. Exercise and leisure: Walks occasionally for exercise. Sleep: Denies any issues with sleeping.
Diet: Drinks one cup of coffee a day, otherwise drinks water or tea. 24-hour recall: Breakfast – bacon and eggs with a black coffee; Lunch – ham sandwich with tea; Dinner – salad with steak. “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History No pertinent family history reported.
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