Comprehensive SOAP Note Template

ComprehensiveSOAP Note Template

Patientinitials: S. J Age: 77 Gender: Female

SUBJECTIVEDATA

ChiefComplaint (CC):The patient is a seventy-seven old female who came for medicalcheckup after she noticed rashes on some parts of the body. Theproblem started one week ago, and the rashes are mostly on the back,face, and abdomen. She also complained of severe pain, especially inthe evening.

Historyof Present Illness (HPI):For several years, the seventy-seven years old female had beentreated for hypertension. She was hospitalized five years ago with amild MI.

Medications:

Allergies:Erythromycin

PastMedical History (PMH):mumps and chickenpox during childhood

PastSurgical History (PSH):No surgical history

Sexual/ReproductiveHistory:Normal

Personal/SocialHistory:Married for fifty years and have three daughters and one son.

ImmunizationHistory:No clear information

SignificantFamily History:Father died of heart attack, the mother for Alzheimer.

Lifestyle:does not smoke or drink.

ReviewOf The System:No fever or weight loss

OBJECTIVEDATA

PhysicalExam:

VitalSigns:Weight 195 pounds Temperature: 35°C Pulse: 46 BP: 188/96

General:The patient is well groomed and in a normal mood. She always appearsto have some knowledge about skin diseases.

ASSESSMENT

Onconducting a physical assessment, there were painful rashes aroundthe neck, abdomen, hands, and the face. Herpes zoster is possiblebecause of the rashes location, distribution, and pain. Dermatitis isalso another likelihood of the rashes. Finally, the patient may alsobe suffering from cellulitis, though her temperature is normal(Dains, Baumann, and Scheibel, 2012).

PLAN

TreatmentPlan:For pain relief, the patient will use Tylenol.

HealthPromotion:The patient is encouraged to avoid rubbing or scratching the rashesto avoid bleeding. Additionally, the patient is recommended to visitrheumatologist if the condition worsen.

DiseasePrevention:The patient is recommended to use medicated soap, as well as thetopical steroid. She is also recommended for UVB therapy.

REFLECTION

Fromthis experience, I have learnt that is wise to have a background ofvarious diseases. This helps in ruling out the precise cause of acertain condition. I believe that above SOAP notes are correct basedon my knowledge and observations that I made.

References

Dains,J. E., Baumann, L. C., &amp Scheibel, P. (2012). Advanced healthassessment and clinical diagnosis in primary care (4th ed.). St.Louis, MO: Elsevier Mosby.