Dominique Azor

Seminar Soap Note Fall 2016

S. This is a 57 years old Black male that presented to the clinic with
complaints of a rash on the left side of his torso for the past two weeks.
He complains of itching redness burning sensation and vesicles to the
site. They cause him a great deal of pain. He rates the pain 9 on a
scale of 10. He mentions that the pain was so intense he thought that
he had pulled a muscle. He denies injury, surgery or trauma. He has
not travelled out of the country for the past two years. He mentions
that this rash is getting worse. He also complains of headache, nausea
and vomiting and generalized weakness. As if he is coming down with
something. He denies any possibility of a fever. Patient states that he
has been a high School teacher at Midwood High School for the past 4
years. He was taking two Tylenol for pain but this is no longer helpful.
His medical history consists of diabetes type 2, hypertension and
hypercholestolemia, which are well controlled with medication. He is
married with two teenage boys. Patient smokes a pack of cigarette per
week but denies drinking with NKDA.

O. Patients Vital signs are T 99, P 85, rr 20, BP 140/80 and BMI34
On examination of the skin, it is warm to touch brown, dry, with instant
turgor recall, good mobility no area of induration or pain. Few macules
noted at both upper and lower extremity. Unilateral lesion with
vesicles noted on left side of trunk. Nails without clubbing or cyanosis.
Head is normal cephalic a traumatic.

A. Differential Diagnosis
Poison Ivy
Contact dermatitis
Herpes Zoster
Insect bites

Patient diagnosed with Herpes Zoster

P. Prescribe patient with Acyclovir 800 mg PO 2 times a day for two

weeks. Patient can continue to take Tylenol 650 q6rs. as needed for
pain. Patient counseled about the importance of smoking cessation and
weight reduction. Ordered Influenza vaccination and Prevnar 13.
Follow up appointment in two months.