SOAP NOTE Differential Diagnosis for Skin Conditions Skin Condition Picture # 2 Patient Initials: __JB___ Age: __47___ Gender: __M___ SUBJECTIVE DATA: Chief Complaint (CC): Red lesions on trunk of body History of Present Illness (HPI): Joe Brown is a 47-year-old Caucasian male who presents to practice with complaints of red lesions on the trunk area. The red lesions developed two weeks ago of his body. The patient has not reported any irritating or soothing factors, and he has not tried any treatment for the lesions. Joe Brown reports the lesion does not affect his daily lifestyle and in not impacting in a negative way. Joe is just worried it could be something more severe. Medications: 1 Lopressor 25mg twice daily 2 Lovastatin 40mg at bedtime 3 Xarelto 20mg daily with dinner Allergies: Penicillins- rash, Past Medical History (PMH): 1 Hypertension diagnosed at 44 2 Atrial Fibrillation diagnosed at 46
3 Dyslipidemia diagnosed at 42 Past Surgical History: Vasectomy (2010) herniorrhaphy (2008) Sexual/Reproductive History: Patient denies any issues reproductively. Patient is currently divorced with 2 children and had a vasectomy in 2010. Patient has no history STDs and all sexual encounters have heterosexual. Personal/Social History: Patient smoked 1 packs of cigarette/day x 10 years and drinks 2 bottles of beer a week for 26 year. Patient denies ever using recreational drugs. Patient does not exercise regularly but considers himself active due to the nature of his job (construction worker). Patient admits he does not follow a prescribed diet he still consume food high in fat and salt.
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- Summer '15
- Rash, Medical diagnosis, Mr. Brown, Joe Brown