Dermatology SOAP Note Transcription Sample Report
SUBJECTIVE: The patient comes in today with a slightly tender spot on the left helix of the ear. He notes that it is sore a little bit at night when he sleeps on it, but not appreciably so. He noted it first at the end of March and just wants to make sure it is harmless and not a cancer. Other than it being tender, he has no other symptoms related to this, and he has not treated it in any way.
OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included his left ear.
ASSESSMENT AND PLAN: Rule out chondrodermatitis nodularis helicis versus actinic keratosis. On the left helix, he had a crusty scaly patch that was about 2 mm in diameter, and the lesion was numbed with lidocaine/epinephrine and a shave biopsy was done to rule out actinic keratosis. If it is negative for actinic keratosis, we discussed with him that he can simply leave it, or if he becomes too symptomatic, we certainly could try to inject it with Kenalog.
We will see him back in Dermatology on an as-needed basis.
Dermatology SOAP Note Sample #2
SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in today for a skin check and also psoriasis check. He had psoriasis on the last visit, on his right palm, and he also notes a spot on his right thumb that he tends to pick at and is always a little bit fissured, but he is not using any medication on this. The last time I saw him, he noted it did not bother him, so although he had some triamcinolone at home, he was not using it. He notes today that his lower legs itch and, in particular, the normal skin on lower leg itches rather than a red, rashy skin that I see today. He also notes he has multiple brown spots on his trunk and wants me to check them.
OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.
ASSESSMENT AND PLAN:
1. Psoriasis: He had three pink scaly patches on his lower legs consistent with psoriasis, and I am going to give him Lidex ointment to apply twice a day to these patches. Also, on his hand, he had some hyperkeratosis of the palm as well as fissuring on his right thumb and this is also consistent with psoriasis. I am going to have him use the Lidex there as well.
2. Itchy legs and dry skin: On his lower legs, he had some dry skin in addition to the patches of psoriasis. I discussed he can use Sarna lotion as needed and Cetaphil or Eucerin moisturizing lotion there as well.
3. Seborrheic keratosis: On his trunk, he had multiple brown plaques consistent with benign seborrheic keratoses. No treatment needs to be done.
We will see him back in six months in Dermatology to check his psoriasis.
Dermatology SOAP Note Sample #3
SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for a skin check. Her last one was on MM/DD/YY. She has had a basal cell skin cancer on left chest on MM/DD/YY and then, in YYYY, she had a squamous cell carcinoma in situ on her nose. She has no new or changing lesions she is concerned about today. She is battling stomach cancer and is in remission currently. She has had metastasis to the lungs with resection of that in the past.
OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.
ASSESSMENT AND PLAN:
1. History of basal cell skin cancer and squamous cell carcinoma in situ on her left chest and left nose: She had no evidence of recurrence in the scar site of each of these areas.
2. Nevi: She had a few brown macules and papules scattered on torso and extremities with none concerning for malignancy.
We will see her back in Dermatology in a year.
