SOAP Note # _____
Main Diagnosis: Herpes Zoster
PATIENT INFORMATION
Name: Ms. GP
Age: 78
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Peanut, Iodine
Current Medications:
Insulin Lantus 100 u/ml: 15 units in the morning and at bedtime
Metformin 500 mg: 1 tablet PO once a day
Atorvastatin 20 mg: 1 tablet PO at bedtime
PMH:
Diabetes mellitus type II
Hyperlipidemia
Varicella (Chickenpox) at the age of 20 years
Immunizations: Flu vaccine in 2020, COVID-19 (Pfizer) in 2021
Preventive Care: Wellness exam on 03/2021
Surgical History: Appendectomy 20 years ago
Family History: Daughter, 48 years old, hyperlipidemia
Social History: Widow, lives with daughter, Catholic religion. No alcohol or smoking. No history of drug use, sedentary lifestyle. Does not work.
Sexual Orientation: Straight
Nutrition History: Regular diet, low in carbohydrates and fat.
Subjective Data:
Chief Complaint: “I have been feeling itching and pain on my right lower back” started 3 days ago.
Symptom analysis/HPI: Ms. GP, a 78-year-old Hispanic woman, is complaining about itching, pain, or tingling on her right lower back. The symptoms started 3 days ago and have worsened. She feels discomfort when anything touches the affected area. She denies fever but reports fatigue, chills, and a mild headache. Today, she noticed redness in the area, prompting her to seek Assessment by her primary care provider.
Review of Systems (ROS)
CONSTITUTIONAL: Fatigue, chills. Denies weakness, thirst, or weight loss. No fever.
NEUROLOGIC: Mild headache. No dizziness, changes in LOC, or weakness in extremities. No history of tremors or seizures.
HEENT: Denies head injury or pain.
Eyes: Denies blurred vision or diplopia. Uses reading glasses.
Ears: Denies tinnitus, ear pain, or ear drainage.
Nose: No nasal obstruction, discharge, or bleeding (epistaxis).
Throat: No sore throat, hoarse voice, or difficulty swallowing.
RESPIRATORY: Denies shortness of breath, cough, expectoration, or hemoptysis.
CARDIOVASCULAR: Denies chest pain or tachycardia. No orthopnea or paroxysmal nocturnal dyspnea.
GASTROINTESTINAL: Denies abdominal pain, discomfort, flatulence, nausea, vomiting, or diarrhea. Bowel movement every other day, with the last one today. No visible rectal bleeding.
GENITOURINARY: Denies polyuria, dysuria, burning urination, hematuria, lumbar pain, or urinary incontinence.
MUSCULOSKELETAL: Denies falls or pain. No clicking or snapping sound in joints.
SKIN: Reports itching, pain, or tingling sensation on her right lower back.
HEMO/LYMPH/ENDOCRINE: No swelling of glands in the groin. Denies bruising or abnormal bleeding.
PSYCHIATRIC: Denies anxiety, depression, hallucinations, delusions, or mood changes.
Objective Data:
VITAL SIGNS:
Temperature: 98.4 °F
Pulse: 82 bpm
Blood Pressure: 122/71 mmH
Vital Signs (continued):
Respiratory Rate: 19 breaths per minute
Pulse Oximetry (room air): 97%
Height: 5’3″
Weight: 164 lb
BMI: 30.2 (obese)
Pain Level: 6/10
GENERAL APPEARANCE:
Ms. GP is an alert and oriented adult female.
NEUROLOGIC:
Alert and oriented to person, place, and time.
Cranial nerves from I to XII intact.
Sensation intact in bilateral upper and lower extremities.
Bilateral upper and lower extremity strength is 5/5.
Pupils are normal in size and equal.
Deep tendon reflexes present.
HEENT:
Head: Normocephalic, atraumatic, symmetric, and non-tender. No tenderness in the maxillary sinuses.
Eyes: No conjunctival injection or icterus. Visual acuity and extraocular eye movements intact. No nystagmus observed. Patient wears glasses.
Ears: Bilateral external canals are patent, without redness or drainage. Tympanic membranes are intact with a pearly gray color and sharp cone of light. No pain or edema noted.
Nose: Nasal mucosa appears normal without irritations.
Mouth: Oral mucosa is pink. The tongue is central, with normal distributed papillae and no lesions detected. The patient has upper and lower dentures that fit properly. Lips show no lesions.
Neck: No lymphadenopathy noted. No jugular vein distention. No swelling or masses in the thyroid gland. No thrills detected on auscultation.
CARDIOVASCULAR:
S1S2 heart sounds are regular in rate and rhythm. No murmurs or gallops detected. Capillary refill is less than 2 seconds. Peripheral pulses are present and symmetric. No edema observed in the lower extremities.
RESPIRATORY:
Lungs: Clear breath sounds auscultated bilaterally. Chest wall is symmetric with no deformities or intercostal retractions. No dyspnea or orthopnea reported. No egophony, pectoriloquy, fremitus, or signs of consolidation noted on palpation. Resonance is equal in both hemithoraces. No rales, wheezing, or rhonchi heard.
GASTROINTESTINAL:
Abdomen is soft and non-tender. Bowel sounds are present in all four quadrants. No bruits detected over aortic or renal arteries. Last bowel movement occurred today.
GENITOURINARY:
Costovertebral angles are non-tender, and kidneys are not palpable. External genitalia appears normal without enlargement or palpable tumors. Redness noted in the groin area.
MUSCULOSKELETAL:
No pain elicited upon palpation. Active and passive range of motion is within normal limits. No stiffness observed.
INTEGUMENTARY:
Ms. GP has a painful red rash with crops of vesicles on an erythematous base. The lesions are in a linear distribution and do not cross the midline. Some blisters are filled with purulent fluid, while others are crusted. The affected area appears swollen and red.
ASSESSMENT:
Ms. GP, a 78-year-old Hispanic woman with a history of Diabetes Mellitus Type II and Hyperlipidemia, presents with itching, pain, and tingling on her right lower back for the past 3 days. Physical examination reveals a characteristic rash with vesicles and erythema in a linear distribution. Based on clinical Assessment, history,
