SOAP Evaluation
1. Sign and symptoms/Clinical presentation of disease process
a. How did your patient present: 62 y.o. white, female patient with past medical history of hypertension, diabetes mellitus, hypercholesterolemia, hypothyroidism, and obesity presented with chief complaint of a painful vesicular rash on her back down to her waist. “The rash is very painful. It’s a continuous stabbing, burning pain.” She rates the pain 8/10. Pt. reports self-medicating with NSAID, but it was ineffective. She reported that what she’s experiencing makes it difficult for her to perform her usual activities. She stated that the same area where the rash is located started out as red bumps about 3-4 days, ago. She denies fever, chills, nausea and vomiting.
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