Episodic SOAP Note: Tom Walker |NRP 531,Latest 2020 complete, Already graded A

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EPISODIC SOAP NOTE: TOM WALKER 2 DOS: 4/15/2019 ID: Tom Walker (M) DOB: 6/28/73 (45) CC: Atopic dermatitis (eczema) and right knee pain Subjective HPI: Tom is a 45-year-old Caucasian male who is... deemed a reliable historian who presents with c/o an episodic flare of eczema which started a month ago (9/10) which is really bad in the bends of his arms and right knee pain which began four days ago after an injury playing basketball. He describes the itching being so bad it keeps him awake at night and his skin has little cracks that bleed. Aggravating factors include taking hot showers he reports he itches more after them. Relieving factors include mild improvement with OTC hydrocortisone cream. Tom reports he has had these flareups in the past. Tom reports that when the injury to his knee occurred, he heard a “pop” and was carried off the floor. He reports that he can not bear weight on his knee and has been using crutches to move around. Tom reports the swelling and bruising as intense and has been using ice, elevating the knee, wearing an ace bandage and taking Tylenol extra strength at the advice of his mother who is a nurse with mild improvement. Denies having fever, chills, weight gain or loss, dizziness, difficulty in swallowing, high blood pressure and depression. Past Medical History: Eczema. Surgical History: Arthroscopic meniscus repair 2009 in which he denies any pain prior to new injury and an appendectomy 8/18. Family History: Mother has high cholesterol and brother is obese with hypertension. Medications: Denies taking medication on regular basis but currently using OTC hydrocortisone crème for eczema and extra strength [Show More]

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