Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

SOAP Note: Jack Baldwin VE iHuman Case

Name:K. P.Date: 09/03/20xxTime: 0800
Age:34Sex: Male
SubjectiveCC: “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

TestResultReference Range
White Blood Cells19500 mm34000-10000
Red Blood Cell Count5.0 million/µl4.5-5.9 (♂), 4.0-5.2 (♀)
Hemoglobin14.2 g/dL14-18 (♂), 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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