MSN 5700 Herpesviral Vesicular Dermatitis Worksheet

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PRIMARY CARE SOAP NOTE PATIENT INFORMATION: NAME: E.M. AGE: 44-year-old SEX: Female CC: “I feel my face very hot, red, flushed, and with painful pimples.” SUBJECTIVE: HPI: A 44-year-old Caucasian female presents to the clinic with a chief complaint of flushing of facial skin with redness, and painful pimples and bumps in nose, cheeks, and chin areas. Patient reports the onset as gradual, increasing in the last year and worsen by heat exposure and spicy food. Patient denies any itching, bleeding, discharge from the lesions, or taking any medications, antibiotics, astringents, toners, or any new skin care products. Patient reports that her mother has a history of rosacea and she thinks that she has it too. Patient is married, sexually active monogamous with husband, and denies any history of STDs or HIV. Patient denies any recent weight changes, fatigue, joint pain, fever, or chills. ALLERGIES: No known allergies to drugs, food, latex, chemicals, or to any environmental factors. CURRENT MEDICATIONS: -Probiotic PO, 1 Capsule, Daily -Vitamin C 1000 mg PO, 1 tablet, Daily -Vitamin D, 1 tablet PO, Daily -Vitamin E, 1 tablet PO, Daily PMHX: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ DEVELOPMENTAL HX: Unremarkable CHILDHOOD ILLNESSES: Chicken pox at the age of 4 years. ADULT AND CHRONIC ILLNESSES: None, healthy. HOSPITALIZATION AND ACCIDENT(S) HX: For gallbladder removal, in 2007 and for childbirth x 2 vaginal deliveries, in 2007 and 2010. SURGICAL HX: Cholecystectomy, in 2007. OBSTETRIC HX: Gravida 2/Para 2/Abortion 0 HISTORYOF BLOOD TRANSFUSION: None SCREENING TESTS HX: Yearly PCP checkups. Last pap smear 9 months ago, normal. Last mammogram 9 months ago, normal. PRIMARY CARE SOAP NOTE IMMUNIZATION HX: Childhood immunization up to date. Influenza vaccine in October of 2020 and COVID-19 vaccine, Pfizer x 2 doses, in April of 2021. NUTRITION: Balanced and varied diet. FAMH: ▪ ▪ ▪ ▪ -MOTHER: Alive, HTN. -FATHER: Alive, HTN and high cholesterol. -BROTHER(S): One, alive, high cholesterol. -SISTER(S): One, alive, healthy. SOCHX: ▪ ▪ ▪ ▪ -TOBACCO: None -E-CIGARETTE/VAPING: None -ALCOHOL: 1 to 2 glasses of red wine on the weekends. -DRUG ABUSE: None SAFETY: Feels safe at home. OCCUPATION: Middle school teacher. ACTIVITY/EXERCISE: Active, walks 4 to 5/week, for 3 to 4 miles. REVIEW OF SYSTEMS: CONSTITUTIONAL: The patient appears well-developed with a normal weight, and a healthy appearance. She denies any appetite or weight changes, fever, chills, fatigue, or weakness. Patient reports sleeping well, 7 to 8 hours per day. HEENT: HEAD: Patient denies any unusually frequent or severe headaches, head injury, dizziness, syncope, vertigo, or balance issues. EYES: Patient denies any difficulty with vision, blurred or double vision, flashing lights, redness, excessive tearing, pain, or discharge. EARS: Patient denies hearing loss or difficulty hearing, tinnitus, vertigo, earaches, infection, or discharge. PRIMARY CARE SOAP NOTE NOSE: Patient denies recent cold, nasal stuffiness, runny nose, nose bleeding, nose itching, nose pain, sinus pain or any problem with sinuses. THROAT/MOUTH: Patient denies any bleeding of gums or dentures, sore tongue or throat, no hoarseness, dysphagia, or mouth, tongue, or throat lesions. Last dental exam with cleaning, 8 months ago. Self-care: brushes teeth 3 to 4/day with flossing x 2/day. NECK: Patient denies any pain, limitation of motion (ROM), no rigidity, no lumps, or swollen glands history. Patient denies any neck injury, accident, or trauma. BREASTS: Patient denies any history of breast pain, lump, nipple discharge, rash, swelling, or trauma. Patient denies any history of breast disease in self or family. Patient reports monthly self-exams at home, normal. RESPIRATORY: Patient denies any history of lung disease, no chest pain with breathing; no cough, no shortness of breath, wheezing, cyanosis, hemoptysis, or chest pain history. Patient denies any history of exposition to toxic chemicals or gasses. CARDIOVASCULAR: Patient denies any history of chest pain, palpitation, syncope, heart murmur, dyspnea with exertion, orthopnea, nocturia, chest discomfort, lower extremities edema, claudication while walking, or leg cramps. No history of deep vein thrombosis, swelling, or pain in calves, legs, or feet. No color changes in fingertips or toes with changes in temperature (cold). GASTROINTESTINAL: Patient denies any nausea, vomiting, heartburn, diarrhea, or constipation. No history of rectal bleeding or black or tarry stools, hemorrhoids, or difficulty swallowing. Patient reports last bowel movement, two days ago, formed, brown. GENITOURINARY: Patient denies frequency, urgency, dysuria, polyuria, nocturia, hematuria, kidney, or flanks pain. Patient denies any history of kidney stones, urethra edema, or discomfort. No suprapubic pain, weak or bifurcated urine stream. Patient reports as sexually active and monogamous with husband, using condoms for birth control. Patient denies any bladder/urinary incontinence. Patient denies any history of STDs with last pap smear 9 months ago, normal, and last menstrual period, two weeks ago, with regular periods. MUSCULOSKELETAL: Patient denies any history of musculoskeletal disease; no arthritis, gout, muscle, or joint pain, weakness, swelling, deformity, stiffness, backache. Or ROM limitation of upper or lower extremity, and no bone trauma. NEUROLOGIC: Patient denies any history of seizure, epilepsy, dizziness, tremors, falls, syncope, numbness, vertigo, changes in orientation, memory, judgment, paralysis, or speech difficulty. PRIMARY CARE SOAP NOTE PSYCHOSOCIAL: Patient denies any history of anxiety, depression, mood, changes, or nervousness. No suicidal ideation, thoughts, or intent during adolescent years or now. OBJECTIVE: CONSTITUTIONAL: Patient AAO x 4 (person, place, time, and situation) at this moment. Well-developed appearance, well-nourished, with mild flushing of the skin (in face), wondering without difficulty, with a normal posture and position. No obvious physical deformities, with pace and gait, are not characteristic of a pathological process, not the assistive device. Normal voice with well-articulated speech, appropriate content, and pattern. Patient speaks English and Spanish; left-handed. It seens to have good hygiene habits. Cooperative and pleasant during the examination. VITAL SIGNS: BP- 126/72 mmHg; HR- 74 bpm (regular); RR-16 bpm; Temp- 98.8°F (37.1°C); O2Sat-98 % (at room air). HEIGHT: 5’5”/WEIGHT: 142 lbs./ BMI: 23.6 WAIST CIRCUMFERENCE: 50 cm. SKIN: Flushed facial skin with erythematous papules with tiny pustule at the crest noted in nose x 1, right cheek, and in chin area, measuring approximately 8 mm. Telangiectasia noted in bilateral cheeks. No rash, birthmarks, hirsutism, pruritus, or distal cyanosis. Hair: average texture and distribution, scalp without lesions or dry flaky scalp. Nails: normal color, consistency, and shape. No clubbing, biting, or discoloration, and no fungal lesion noted. Nailbeds: pink and firm with prompt capillary refill. HEENT: Head: Normocephalic, symmetrical, atraumatic, no injuries, lesions, lumps, scaling, parasites, or tenderness of the scalp. Hair with adequate implantation, distribution, and without seborrhea, pediculosis, masses, peeling, or redness. Face: symmetrical, no weakness or involuntary movements. Eyes: EOMs intact, no nystagmus, ptosis, lid lag, discharge, or crusting. Corneal light reflex present, symmetric, round, no strabismus. No alopecia, eye lashes with uniform distribution and good quantity. Conjunctivae clear, wet, without injuries. Sclerae white, no lesions or redness, non-icteric. No exophthalmos. Snellen chart test normal. Pupils equal, round, and reactive to light accommodations (PERRLA), constrict from 5 mm to 2 mm; disc margins are sharp. Ocular fundus: no hemorrhage, edema, or spots. Ears: normal appearance and implantation, symmetrical. Auditory meatus normal. Ear movements and push tragus no painful, right sided. In both ears a tympanic membrane luminous PRIMARY CARE SOAP NOTE cone of light and normal structures/anatomy can be seen. Rinne and Weber tests normal. Whispered voice test normal. No hypertrophy of posterior auricular lymph nodes. Nose: symmetrical, no deformities, or tenderness to palpation. Nares patent, mucosal pink, no lesions, adequate size, no hypertrophy. Nostrils permeable, no bleeding, no deviations. Sinuses: Frontal and maxillary sinuses soft, nontender. Throat/Mouth: lips pink, without masses, cracks, or peeling, wet moisture. Oral mucosa and gums pink and moisture. Good dentition, no prosthesis. Tongue pink, symmetric, normal shape, no ulcerations, no deviations or swelling. NECK: Symmetric. Proper range of motion (ROM). Not painful to anterolateral flexion, extension, or rotation movements. No lymphoid hypertrophy. No masses. Carotid pulse rhythmic and good tone. No bruit. Trachea is midline. No jugular venous distention. Thyroid not visible or palpable; no thyromegaly. BREASTS: Symmetric, no nipple retraction, discharge, redness, swelling, or lesions. Contour and consistency firm and homogenous. No masses or tenderness, no lymphadenopathy. RESPIRATORY: Inspection: AP

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