SOAP / Chart / Progress Notes
Sample Name: Poison Ivy - SOAP
Description: Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.
(Medical Transcription Sample Report)
SUBJECTIVE: He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg. He said that it worked fairly well, although it seemed to still take awhile to get rid of it. He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.
Vitals: Temperature is 99.2. His weight is 207 pounds.
Skin: Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.
ASSESSMENT AND PLAN: Poison ivy. Plan would be Solu-Medrol 125 mg IM X 1. Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.
Keywords: soap / chart / progress notes, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison,