Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples
SOAP Note: Jack Baldwin VE iHuman Case
| Name: | K. P. | Date: 09/03/20xx | Time: 0800 |
| Age: | 34 | Sex: Male | |
| Subjective | CC: “I have a burning red rash on my back.” | ||
| HPI: 34-year-old male presents with a linear vesicular rash to the right side of his back. Tingling and burning sensation started 48 hours ago, blisters appeared 24 hours ago. Constant sharp, burning pain (8-10 severity). Generalized malaise, low-grade fever. Pain worsens with touch and movement. Pain controlled with Tylenol 650 mg PO. History of chickenpox at age 5. | |||
| Medications: | Benicar 10 mg PO daily for HTN | ||
| PMH: | Allergies: NKDA, Medication Intolerances: None | ||
| Chronic Illnesses: | HTN (401.1) – controlled | ||
| Hospitalizations: | None | ||
| Immunizations: | Up to date. Flu shot in October 2012. Tetanus booster in 2010. | ||
| Environmental Hazards: | None | ||
| Safety Measures: | “I always wear my seatbelt.” | ||
| Exercise and Leisure: | Walks occasionally for exercise. | ||
| Sleep: | No issues reported. | ||
| Diet: | Drinks one cup of coffee a day. 24-hour recall: Breakfast – bacon and eggs with black coffee; Lunch – ham sandwich with tea; Dinner – salad with steak. | ||
| Family History: | No pertinent family history. | ||
| Social History: | No tobacco, alcohol, or illicit drugs. | ||
| Education level: Not specified, Occupational history: Not specified, Current living situation/marital status: Not specified. | |||
| ROS: | General: Pain and rash on the right side of the back. Otherwise, no complaints. | ||
| Cardiovascular: No chest pain, palpitations, PND, orthopnea, or edema. | |||
| Skin: Complaints of rash to the middle of the right side of the back. Sharp, burning pain reported. No other abnormalities noted. | |||
| Respiratory: No cough, wheezing, hemoptysis, dyspnea, pneumonia history, or TB. | |||
| … (Continue for other systems) |
Objective
| Vital Signs: | Weight: 182 lbs, BMI: 24.0, Temp: 99.2 F, BP: 122/84, Pulse: 82 per minute, Resp: 18, O2 sat 100% on RA |
| General Appearance: | 34-year-old white male, appears his stated age. Not in distress, well-groomed, well-nourished, hydrated, alert, oriented X3. |
| Skin: | Rash present on the mid-back, right side, linear form, vesicular blisters intact, no exudate or crusting. No other skin abnormalities. |
| HEENT: | Normocephalic, atraumatic, no lesions. PERRLA, EOMs intact. Canals patent, TMs pearly grey. Nasal mucosa pink. |
| Cardiovascular: | PMI at 5th ICS MCL. S1, S2 present. No murmurs, thrills, or lifts. Pulses 3+ throughout. No edema. |
| Respiratory: | Symmetrical thoracic expansion, clear to auscultation bilaterally. Regular and easy respirations. |
| Gastrointestinal: | Abdomen obese; BS active in all 4 quadrants. Soft, non-tender. No hepatosplenomegaly. |
| Genitourinary: | Left groin visibly swollen and indurated. Tenderness in the left inguinal canal. Scrotum swollen on the left side. Testicles normal. |
| Musculoskeletal: | Full ROM in all 4 extremities. |
| Neurological: | Clear speech, good tone, erect posture, stable balance, normal gait. |
| Psychiatric: | Alert and oriented. Dressed appropriately. Maintains eye contact. Clear and normal rate speech. |
Note: Continue the objective information for lab results and other relevant data.
SOAP Note: Jack Baldwin VE iHuman Case
Lab Results
| Test | Result | Reference Range |
| White Blood Cells | 19500 mm3 | 4000-10000 |
| Red Blood Cell Count | 5.0 million/µl | 4.5-5.9 (♂), 4.0-5.2 (♀) |
| Hemoglobin | 14.2 g/dL | 14-18 (♂), 12-16 (♀) |
| … (Continue for other lab results) |
Note: Present other lab results in a similar tabular format.
Diagnosis and Differential
| Diagnosis: | Herpes zoster without mention of complication (053.9) | | Differential Diagnoses: | 1. Rash and other nonspecific skin eruption (782.1) | | | 2. Other malaise and fatigue (780.79) | | | 3. (Add another diagnosis) |
Note: Present other differential diagnoses in a similar tabular format.
Plan/Therapeutics
| Plan: | – Diagnosis: Herpes zoster without mention of complication (053.9) | | | – Further testing: None | | | – Medication: Valtrex 1000 mg PO q8h X 7 days | | | – Education: (Provide detailed education points) | | | – Non-medication treatments: (Provide details) | | | – Return to clinic: RTC in one week if pain persists or s/s of infection occur. Otherwise, PRN. |
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