6512 soap.docx - 1 Running head COMPREHENSIVE SOAP 2 COMPREHENSIVE SOAP Comprehensive SOAP Patient Initials KD Age 45 Gender F SUBJECTIVE DATA Chief

6512 soap.docx - 1 Running head COMPREHENSIVE SOAP 2...

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2 COMPREHENSIVE SOAP Comprehensive SOAP Patient Initials: KD Age: 45 Gender: F SUBJECTIVE DATA: Chief Complaint (CC): I have a rash on my chest. (#5) History of Present Illness (HPI): K.D., 45-year-old Caucasian female presents to the clinic today with the chief complaint of a rash on her chest that began one week ago. She states that the rash is dry, itchy, and no drainage observed. The rash worsens at bedtime. She denies any recent exposure to any new allergens. For the past two days she has been using OTC Cortisone cream and Benadryl tablets. This regimen has given her some relief. She rates discomfort 6/10 severity on pain scale. Medications: OTC Benadryl 50 mg PO BID OTC Cortisone cream 1% applied topically BID to affected area on chest Lisinopril 10 mg PO Daily Protonix 40mg PO Daily Ambien 5 mg PO QHS PRN Insomnia Allergies: NKDA Past Medical History (PMH): 1. Hypertension – well controlled with medications. Diagnosed at age 40. 2. Insomnia – works night shift and has difficulty sleeping at times. Controlled with PRN sleep aids. Diagnosed at age 35. 3. GERD – Controlled with PPI and diet modifications. Diagnosed at age 40. Past Surgical History (PSH):
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3 COMPREHENSIVE SOAP 1. Tonsillectomy as a child Sexual/Reproductive History: Gravida 1; Para 1. Normal menses. LMP 18 days ago. Personal/Social History: Never smoked. Drinks socially – less than 4 glasses of wine per month. Denies any illicit drug use. Works as a secretary at a law firm. Married to husband for 15 years and they have one female child that is 15 years of age. They have smoke and carbon monoxide detectors in their home. Low fat diet for GERD. Exercises three times a week with treadmill for approximately 30 minutes. Interests include reading. Uses her seatbelt when
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  • Summer '15
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