Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style

Skin Comprehensive SOAP Note

Patient Initials: D.O.             Age: 57 years                         Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): Pain and swelling.

History of Present Illness (HPI): D.O. is a 57-year-old Caucasian female who presents with pain and swelling on her right leg for the past two weeks. She reports that she doesn’t recall experiencing any trauma on her right leg. She remembers experiencing pain and swelling in her right leg, which progressively became red and tender. Later on, she noticed an ulcer on her right leg. D.O. rates the pain on a scale of eight out of ten. She explains that the pain limits her movement and worsens when she tries to walk. She bought an over-the-counter cream whose name she doesn’t recall and paracetamol tablets. The cream and pills temporarily relieved the pain and swelling. D.O. highlights that she has been experiencing fever and fatigue intermittently for the past week.

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Medications:

Paracetamol 1000mg TDS PRN

Metformin 500mg BD

Glibenclamide 10mg BD

Allergies: No known drug allergy. No known food allergy.

Past Medical History (PMH): She has been a known diabetic for the past twenty years, which she manages by taking metformin and glibenclamide.

Past Surgical History (PSH): Caesarian section (1995).

Sexual/Reproductive History: Heterosexual.

Personal/Social History: She occasionally takes alcohol and has not smoked cigarettes for the past twenty-seven years.

Immunization History: Her immunization is up to date. She was vaccinated for COVID-19 on 30/11/2021 and 1/1/2022.

Significant Family History: D.O. has two 26-year-old male children who are twins. Her sons are alive and healthy. D.O. is the second born of three children. She has two brothers. One of her brothers is active and healthy, while the firstborn is a known diabetic and hypertensive. D.O.’s mother died from breast cancer, while her father died from diabetes complications. Her paternal grandparents died of diabetes. Her maternal grandmother died of diabetes, while her maternal grandfather died of prostate cancer.

Lifestyle: D.O. is married. She lives with her husband in her own compound house in the suburbs. She was a primary school teacher and took early retirement two years ago to focus on farming. She spends most of her days on the farm with her employees. She maintains a healthy lifestyle by staying active, taking daily walks, and eating a balanced diet. She has comprehensive health insurance.

 Review of Systems:

General: The patient reports fever and fatigue. She denies chills, headaches, night sweats, day sweats, daytime sleepiness, sleep disturbances, weight gain, or weight loss.

HEENT/Neck: The patient denies difficulty swallowing and rhinorrhea. She refuses double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Also, she refuses changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. She also refuses dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion. Her last eye and dental examination were six months ago.

Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.

Cardiovascular/Peripheral Vascular: Reports swelling on the right leg. Denies lightheadedness when standing, paroxysmal nocturnal dyspnea, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies painful urination, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine.

Musculoskeletal: The patient has been experiencing pain in her right leg. She denies muscle pain,