Herpes Zoster SOAP Note Sample Report

DATE OF VISIT: MM/DD/YYYY

SUBJECTIVE: This is a (XX)-year-old female patient of Dr. John Doe who comes in with complaints of a painful rash on her right upper back. She believes she has had it for about two weeks. This is the first time she has been seen for this. She has had a history of shingles on her left chest in the past. The discomfort is worse when she is using her right arm such as doing the dishes or cooking. It is actually better when she is lying on that side. She has been taking Tylenol. She avoids anti-inflammatories because of her history of hypertension.

The patient has a past medical history of hypertension, hyperlipidemia, obesity, chronic obstructive pulmonary disease, mild pulmonary hypertension, and abnormal CT scan.

Medications include aspirin 81 mg daily, Lipitor 20 mg daily, hydrochlorothiazide 50 mg daily, atenolol 100 mg daily, Diovan 80 mg daily, and Spiriva once a day.

OBJECTIVE: Temperature is 97.6. The patient appears well and is in no acute distress. Her pain score, she states, is 8-9/10 at times. At rest, it is better. Currently, as she sits here, it is about 8/10. The patient has a crusted-over vesicular rash on the right lateral upper back, on her right shoulder, and the top of the posterior right upper arm. There are no lesions on the anterior or lateral chest wall. They are not particularly tender to the touch. She does not seem to have any hyperesthesia in the area. She has normal range of motion of her neck and shoulder without limitation.

ASSESSMENT: Herpes zoster.

PLAN: Unfortunately, it has been about two weeks possibly since the onset of the rash; however, since she is not sure and she is having fairly significant pain, we opted to start her on Valtrex anyway, and we have given her Vicodin. We did discuss gabapentin, but for now, she declines but will call if she finds that she is needing to take the Vicodin frequently or if her level of pain continues at its current level.