Patient Initials: AC Age: 68 Gender: Male
SUBJECTIVE DATA: “About a week ago, I noticed some rash on my right chest, back, and neck. I thought it would get better, but the rash is itchy and painful, it has also gotten worse. I also feel a little feverish.” NURS-6512 Differential Diagnosis for Skin Conditions SOAP note
Chief Complaint (CC): The patient reported noticing skin abnormality about a week ago, “I have an itchy rash on my neck, chest, and back that is peeling and getting worse.” The rash is swollen with clear liquid and painful.
History of Present Illness (HPI): Mr. Alexander Cortez is a 58-year-old Hispanic male. Presents with a patchy rash on the neck, chest, and back region. He states that the rash started about two weeks ago and has progressively gotten worse. He denies changing skin routine or location within the last two weeks, no history of environmental allergies, no known allergy to dye, or latex. Mr. Cortez states he has not tried any treatment for the rash, no worsening, or alleviating factors noted. He complained of pain level 7 on a scale of 1-10. He describes the pain as sharp and states Tylenol 1000mg has helped relieve the pain. He is worried about the rash getting worse and states that the rash and its associated pain interferes with his daily activities and quality of life. NURS-6512 Differential Diagnosis for Skin Conditions SOAP note
Medications:
– Acetaminophen 1000mg
PO Q 6 HRS for pain
– Metformin 500mg daily for diabetes
– Atorvastatin 40mg at bedtime for high cholesterol
– Hydralazine 10mg BID for Hypertension
– Amlodipine 5mg daily for hypertension
Allergies:
– Penicillin Reaction (itching)
Past Medical History (PMH):
Past Surgical History (PSH):
Appendectomy 1992
Sexual/Reproductive History:
Currently sexually active with his wife, he denies sexual/reproductive issues. Heterosexual and currently using no barrier methods, no past history of STDs.
Personal/Social History:
The patient is a non-smoker, never smoked. His wife smokes 1pack/day. Mr. Cortez drinks alcohol occasionally, about 1-2 drinks a week. He denies the use of recreational drugs.
Immunization History:
Received flu shot last season
Received pneumococcal vaccine 8/12/2019 during the annual check-up
He does not remember the last tetanus vaccination.
Significant Family History:
-Mother had diabetes mellitus type 2 and died from diabetes complication at 81
-Father had chronic hypertension and died at the age of 78 from a stroke
-Patient does not recall the medical history of grandparents
-Denies any noted illness for his siblings and children.
Lifestyle: Mr. Cortez runs a small family construction business, which he runs with his son. He is a Christian and attends church with his family every Sunday. The highest level of education is high school with certifications in HVAC and plumbing. He lives at home with his wife, daughter, who is a single mother and grandson. His wife works full time as a secretary, and his health coverage is through his wife’s job. He states he is too busy to exercise, and his diet comprises mainly of heavy meals due to his job. Reports drinking socially, about 2-3 drinks weekly, mostly beer. Never smoked, denies the use of recreational or illicit drugs
Review of Systems
General: Mr. Cortez appears well dressed and well-nourished. Denies weakness and fatigue. No recent weight changes or changes in appetite. No apparent signs of distress.
HEENT: The patient uses glasses, denies vision changes, discharge from eyes, tinnitus, hearing loss, and discharge from ears. Denies loss or decreased sense of smell, nasal drainage, or congesti
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