systemic erythematosus lupus, soap notes

 Patient Age: Race: Gender: Insurance: SUBJECTIVE Chief complaint: History of present illness (HPI): Past Medical History(PMH) Last annual physical exam was made in January of current year. Chronic Condition: Current Medication: Hospitalization: Patient denies hospitalizations or invasive procedures. No history of mental illness or personality disorders. No physical trauma or falls reported during the last twelve months. Surgeries: Exposure: Patient lived in a shelter for two months due to economic problems that were already solved. No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues. Environmental exposure was negative to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time. Immunizations: Immunizations up to date (Flu Vaccine: 01/23/2019) Exercise: Diet: Social History: Educational level: Sexual Behavior: Allergies: Family Medical History: Systemic: The systemic symptoms presented at this time is skin itchy. No chills, no neck rigidity. No weight loss. Head: Neck: Eyes:. Oto-laryngeal: Breasts: Cardiovascular: Pulmonary: Gastrointestinal: Genitourinary:. Endocrine: Hematologic: Musculoskeletal: Neurological: Psychological: Skin: OBJECTIVE Physical Exam Vitals Sign: Height 70 in Weight:188 lbs. Body Mass Index: 29.1 Kg/m2 Body Surface Area: 1.97 m2 Oxygen Saturation: 98 % Pain Scale/Rate: 0/10 General appearance: Head: Neck: . Eyes: Ears: Nose: Oral Cavity: Lymph Nodes:. Chest:. Lungs: Cardiovascular: Abdomen: Inspection: Auscultation: Palpation: . Percussion: Genitalia: Rectal: Musculoskeletal: Neurological: Speech clear and fluent. Psychiatric: Skin: Hair: Nails: ASSESSMENT Primary Diagnosis: B86 Scabies Differential Diagnosis: Atopic Dermatitis: is a chronic inflammatory skin condition that appears to involve a genetic defect in the proteins supporting the epidermal barrier. Impetigo: is a contagious superficial bacterial infection observed most frequently in children. Variants of impetigo include non-bullous impetigo, bullous impetigo, and ecthyma Folliculitis: Multiple follicular-based erythematous papules or pustules on chest and back. No burrows seen on physical exam. Other Diagnosis Essential Hypertension (Controlled) I10 Overweight E66.3 PLAN Therapeutic Permethrin 5% cream, massage thoroughly into the skin from the neck to the soles of the feet x 1 time, cream should be removed by washing after 8 to 14 hours. Apply a second time after two weeks. Hydroxyzine tab 25 mg BID for 5 days. Non-Therapeutic Patient was instructed regarding general measures: 1. Treatment for those who were sexual and household contacts within the preceding 1 month is recommended at the same time that the patient is treated to prevent re-infestation. 2. Immediately following any treatment, all bedding and clothing should be washed in water that is 140°F or higher (≥60°C) and dried the day after the first treatment to decrease the chance of re-infestation. 3. Clothing or objects that cannot be washed should be placed in a sealed bag for a week. No Test ordered/No needed to this diagnosis Follow-ups/Referrals: Follow-up in 3 weeks. Also, the patient was instrumented to return if the symptoms get worse. This is an example….. at least 2 reference