Differential Diagnosis for Skin Conditions

Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: B.J.Age: 70Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Image #5 Painful rash and blisters on the back, right side, underarm, and flank.
History of Present Illness (HPI): Ben Juan, a 70-year-old Hispanic man, has been experiencing severe blisters and rashes on the right side of his back for the past few days. The blisters and rash are accompanied by severe fever and burning. B.J. states that the aching began five days ago, was bearable, and was initially thought to be sunburn. The patient reported having a fever three days before this session and observed little sores developing on his back that extended to his underarm and flank. Although the blisters have not opened, he keeps the region covered by his clothes and avoids touching it because it aches badly.
Medications:
1 paracetamol 500mg tabs to control fever
2 Naproxen 200mg tabs, pain medication
3 Cozaar 50mg
4 Crestor 20mg
5 Prozac 20mg tabs, prescribed to manage anxiety
6 Flovent 100mg
Allergies:
No Known Allergies
Past Medical History (PMH):
1 Mini stroke (TIA)
2 High blood pressure
3 Anxiety
4 High Cholesterol
5 Gout
6 Chicken Pox at a young age
Past Surgical History (PSH):
1 Surgery to repair the rotator cuff in 1999
2 A vasectomy was done in 2000
3 Arthroscopic Meniscus Repair in 2008
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He uses tobacco at least a packet of cigarettes a day but denies illicit drug use. He previously used marijuana and cocaine and quit 20 years ago. He regularly spends time exercising for healthy cardio. He likes to spend as much time as he can with his children and grandchildren, as well as go fishing and camping with friends. At social gatherings, he occasionally has a glass of wine or beer.
Health Maintenance:
He is physically active since he regularly exercises for at least 60 minutes and covers 5 miles of walking daily. The patient has annual well-being visits with a primary care provider. Conducts bi-annual dental assessments as well as annual dermatology screenings.
Immunization History:
Patient immunization is updated. All childhood immunizations were administered. He received the Moderna Covid vaccine on April 2021. He has no history of tetanus, pneumovax, and flu vaccines.
Significant Family History:
His father was diagnosed with colon cancer, a previous shingles diagnosis, and hypertension at 98. The mother has breast cancer, hypertension, and stroke at 95. Sixty-five years old brother was diagnosed with chronic kidney disease at age 61. His sister suffers from anemia and hypertension; the youngest sister is diagnosed with breast cancer at age 55. His son, at age 41, has hyperthyroidism. The daughter, at age 35, has no significant medical history.
Lifestyle:
Since 1986, B.J. has been operating a business as the proprietor of an interior design company. He participates actively in his local Catholic church, where he serves as a volunteer at weekly services and other charitable social events. He takes great care of his health and wellness and eats a balanced diet that is largely high in protein, low in sugar, and low in fat....