Week 4 Skin Comprehensive SOAP Note Template Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): History of Present Illness (HPI): Medications: Allergies: Past Medical History (PMH): Past Surgical History (PSH): Sexual/Reproductive History: Personal/Social History: Health Maintenance: Immunization History: Significant Family History: Review of Systems: General: HEENT: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Musculoskeletal: Neurological: Psychiatric: Skin/hair/nails: OBJECTIVE DATA: Physical Exam: Vital signs: General: HEENT: Neck: Chest/Lungs:. Heart/Peripheral Vascular: Abdomen: Genital/Rectal: Musculoskeletal: Neurological: Skin: Diagnostic results: ASSESSMENT: PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses. © 2021 Walden University Page 2 of 3 Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions 1: 2: 3. 4. 5. © 2021 Walden University Comprehensive SOAP Exemplar Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and fever History of Present Illness (HPI): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10. Medications: 1.) Norvasc 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Advair 500/50 daily 4.) Singulair 10mg daily 5.) Over the counter Tylenol 325mg as needed 6.) Over the counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs - rash Cipro-headache Past Medical History (PMH): 1.) Asthma 2.) Hypertension 3.) Osteopenia 4.) Allergic rhinitis 5.) Prostate Cancer Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Prostatectomy 1986 Sexual/Reproductive History: Heterosexual Personal/Social History: He has never smoked Dipped tobacco for 25 years, no longer dipping Denied ETOH or illicit drug use. Immunization History: Covid Vaccine #1 3/2/2021 #2 4/2/2021 ...

1. Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:

2. Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this
course (NURS 6512), but will be required for future courses.

3. © 2021 Walden University
Page 2 of 3
Week 4 Lab Assignment: Differential Diagnosis for Skin
Conditions
1:
2:
3.
4.
5.
© 2021 Walden University
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note
should include. Remember that Nurse Practitioners treat
patients in a holistic manner and your SOAP note should reflect
that premise.
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:

4. Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Eddie Myers is a 58 year old
African American male who presents today with a productive
cough x 3 days, fever, muscle aches, loss of taste and smell for
the last three days. He reported that the “cold feels like it i s
descending into his chest and he can’t eat much”. The cough is
nagging and productive. He brought in a few paper towels with
expectorated phlegm – yellow/green in color. He has associated
symptoms of dyspnea of exertion and fatigue. His Tmax was
reported to be 100.3, last night. He has been taking Tylenol
325mg about every 6 hours and the fever breaks, but returns
after the medication wears off. He rated the severity of her
symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 daily
4.) Singulair 10mg daily
5.) Over the counter Tylenol 325mg as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis
symptoms
Allergies:
Sulfa drugs - rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia

5. 4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother--with prostate CA, dx at age 62. He has 2
daughters, both in 30’s, healthy, living in nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city,
moderate crime area, with good public transportation. He is a
college grad, owns his home and financially stable.
He has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. He has medical insurance but often asks for drug
samples for cost savings. He has a healthy diet and eating

6. pattern. There are resources and community groups in his area
at the senior center but he does not attend. He enjoys golf and
walking. He has a good support system composed of family and
friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or
night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; he does wear glasses
and his last eye exam was 6 months ago. He reported no history
of glaucoma, diplopia, floaters, excessive tearing or
photophobia. He does have bilateral small cataracts that are
being followed by his ophthalmologist. He has had no recent ear
infections, tinnitus, or discharge from the ears. He reported no
sense of smell. He has not had any episodes of epistaxis. He
does not have a history of nasal polyps or recent sinus infection.
He has history of allergic rhinitis that is seasonal. His last
dental exam was 1/2020. He denied ulceration, lesions,
gingivitis, gum bleeding, and has no dental appliances. He has
had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or
compression..
Breasts:. Denies history of lesions, masses or rashes.
Respiratory: + cough and sputum production; denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; he has history of asthma and community acquired
pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.

7. CV: denies chest discomfort, palpitations, history of murmur;
no history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: denies nausea or vomiting, reflux controlled, Denies abd
pain, no changes in bowel/bladder pattern. He uses fiber as a
daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or
incontinence. He is heterosexual. No denies history of STD’s or
HPV. He is sexually active with his long time girlfriend of 4
years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation
in her range of motion by report. denies history of trauma or
fractures.
Psych: denies history of anxiety or depression. No sleep
disturbance, delusions or mental health history. He denied
suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia,
head aches. denies change in memory or thinking patterns; no
twitches or abnormal movements; denies history of gait
disturbance or problems with coordination. denies falls or
seizure history.

8. Integument/Heme/Lymph: denies rashes, itching, or bruising.
She uses lotion to prevent dry skin. He denies history of skin
cancer or lesion removal. She has no bleeding disorders,
clotting difficulties or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies
fatigue, heat or cold intolerances, shedding of hair,
unintentional weight gain or weight loss.
Allergic/Immunologic: He has hx of allergic rhinitis, but no
known immune deficiencies. His last HIV test was 2 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and
regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht:
5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop;
pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness –
diffuse – no rebound
Genital/Rectal: pt declined for this exam
Musculoskeletal: symmetric muscle development - some age
related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
palpable nodes

9. Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Diagnosis (DDx):
1.) Asthmatic exacerbation, moderate
2.) Pulmonary Embolism
3.) Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this
course, but will be required for future courses.]
© 2021 Walden University
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© 2021 Walden University
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