SOAP Note
Student’s Name:
Institutional Affiliation:
Comprehensive SOAP NOTE
Patient Initials: ___N/A____ Age: ___N/A____ Gender: ___N/A____
SUBJECTIVE DATA:
Chief Complaint (CC): #3
History of Present Illness (HPI): A Caucasian male whose age is unknown presents with non-scaly annual papules distributed along his nape. The papules have undiluted borders and appear reddish in color.
Medications: No medical history provided.
Allergies: No known allergies.
Past Medical History (PMH): Past medical history not provided.
Past Surgical History (PSH): No surgical history provided.
Sexual/Reproductive History: Not provided. Ask about his sexuality, the number of sexual partners, pregnancy, and whether the patient has a history of sexually transmitted infections.
Personal/Social History: Not provided. Enquire on his hobbies, place of work, traveling history, and whether he smokes or use any recreational drugs.
Immunization History: Not provided. Collect the patient immunization details.
Significant Family History: Not provided. Inquire if there are family members with any skin complications. Inquire about other family’s medical conditions that might contribute to skin infections.
Review of Systems:
General: Not reported. Inquire for symptoms of fatigue, fever, sweating, or any significant weight changes.
HEENT: Not reported. Inquire about any vision or hearing changes, any chewing or swallowing difficulty, and any nasal complications.
Neck: Red lesions distributed on the back of the neck.
Breasts: No reported complications. Ask if the patient has a history of lesions, masses, or rashes.
Respiratory: No reported complications.
CV: No reported complications.
GI: No reported complications.
GU: No reported complications. Ask if the patient has had any lesions or rashes on his genital areas.
MS: No reported complications.
Psych: No reported complications.
Neuro: No reported complications.
Integument/Heme/Lymph: Red lesions at the back of the neck. Ask if the lesions are present in other parts of the body.
Endocrine: No endocrine symptoms reported.
Allergic/Immunologic: No known allergies.
OBJECTIVE DATA
Physical Exam:
Check for the patient’s vital signs. Vital signs include blood pressure, temperature, heart rate, and body mass index.
General: Check for the patient’s appearance and signs of fatigue and discomfort.
HEENT: Investigate the eyes, ears, and nose for any abnormalities.
Neck: Non-scaly annual papules at the back of the neck. Palpate the lesions to determine the texture and warmness.
Chest/Lungs: Check the chest for the presence or rashes or lesions.
Heart/Peripheral Vascular: N/A
ABD: Check the abdomen for the presence of rashes or lesions
Genital/Rectal: Investigate the genitalia for the presence of rashes.
Musculoskeletal: N/A
Neuro: N/A
Skin/Lymph Nodes: Non-scaly annual lesions at the back of the neck. Check whether there are further lesions on other skin regions.
ASSESSMENT:
Diagnostics:
Lab:
Various laboratory procedures can be used to guide the diagnosis. The following are some of the recommended procedures.
Dermoscopy. The procedure uses a skin surface microscope known as a dermatoscope to magnify the lesion (Colyar, 2015). The process aims at providing a more detailed investigation of the lesion to make a diagnosis and determine the skin lesions that require a biopsy (Colyar, 2015).