Focused Integumentary SOAP Note- Felipe Barbosa Requirements
Module 1 Focused Integumentary SOAP note
SUBJECTIVE
Chief Complaint
“I’m here for this pain and rash on my back.”
HPI (History of Present Illness)
Felipe Barbosa is a forty-eight-year-old Brazilian American male born October 31, 1974.
Patient reports having pain and rash on his lower back. He reports that he experienced a tingling
in the area about four days ago and that pain and a rash broke out about two days ago. The
patient has reported that the pain is constant and has rated it a 7/10 on a pain scale with and
without the use Ibuprofen. He reports that he takes Ibuprofen 200mg tablets about 2-3 times per
day, taking about 800 mg daily and that helps a little bit. He last took Ibuprofen this morning.
He reports the rash as being small red blisters that produce a burning pain on his lower back. He
said that sweating makes the pain worse and that he tried an ice pack, but it did not relieve his
symptoms. Patient denies radiation of pain, chest pain, abdominal pain, and photophobia. He
reports increased tiredness throughout the day and denies having a similar rash in the past.
PMH (Pertinent past medical history)
Patient denies any previously diagnosed medical conditions. Patient denies a history of
back pain, heart disease, spinal surgery, HIV, but does report having chicken pox as a child.
Patient denies any recent surgeries or hospitalizations.
Medications
❖ Ibuprofen 200 mg
o Takes about 2-3 times per day about 800 mg daily PRN for increased pain
in lower back.
Focused Integumentary SOAP Note- Felipe Barbosa Requirements
, Focused Integumentary SOAP Note- Felipe Barbosa Requirements
o Reports feeling little relief of pain from burning rash.
❖ Patient denies taking any vitamin or supplements.
Allergies
Patient denies having any allergies to any food, medications, latex, or environment.
Pertinent Family History, Social History, and other subjective data if relevant
Mr. Barbosa denies having a family history of skin diseases but reports that his father has
high cholesterol and hypertension, and his mom has diabetes. Both parents are still alive, and he
has one brother with no health issues. Patient reports that he lives in a condo with his husband.
He reports being a firefighter and having a strong support group of family, friends, and colleagues at
the firehouse. Patient reports that he lost his best friend who was also a firefighter in the line of
duty in an accident. He reports that it has been hard and that he has started therapy for grief
counseling to help cope with the death of his friend. He denies using tobacco or any illicit drugs
and reports drinking alcohol 1-2 nights per night. He likes drinking one to two glasses of wine
with dinner.
ROS (Pertinent review of systems)
❖ General: Patient reports having more fatigue than usual, denies fever, chills,
and weakness
❖ Head- denies history of trauma, or headaches.
❖ Eyes- denies wearing glasses or contacts, and says vision is good.
❖ GI/GU- denies nausea, vomiting, abdominal pain, or diarrhea.
❖ Musculoskeletal- denies any joint pain, back surgery and reports no recent injuries.
❖ Neuro- denies any weakness, dizziness or any problems with memory or coordination.
Focused Integumentary SOAP Note- Felipe Barbosa Requirements
Module 1 Focused Integumentary SOAP note
SUBJECTIVE
Chief Complaint
“I’m here for this pain and rash on my back.”
HPI (History of Present Illness)
Felipe Barbosa is a forty-eight-year-old Brazilian American male born October 31, 1974.
Patient reports having pain and rash on his lower back. He reports that he experienced a tingling
in the area about four days ago and that pain and a rash broke out about two days ago. The
patient has reported that the pain is constant and has rated it a 7/10 on a pain scale with and
without the use Ibuprofen. He reports that he takes Ibuprofen 200mg tablets about 2-3 times per
day, taking about 800 mg daily and that helps a little bit. He last took Ibuprofen this morning.
He reports the rash as being small red blisters that produce a burning pain on his lower back. He
said that sweating makes the pain worse and that he tried an ice pack, but it did not relieve his
symptoms. Patient denies radiation of pain, chest pain, abdominal pain, and photophobia. He
reports increased tiredness throughout the day and denies having a similar rash in the past.
PMH (Pertinent past medical history)
Patient denies any previously diagnosed medical conditions. Patient denies a history of
back pain, heart disease, spinal surgery, HIV, but does report having chicken pox as a child.
Patient denies any recent surgeries or hospitalizations.
Medications
❖ Ibuprofen 200 mg
o Takes about 2-3 times per day about 800 mg daily PRN for increased pain
in lower back.
Focused Integumentary SOAP Note- Felipe Barbosa Requirements
, Focused Integumentary SOAP Note- Felipe Barbosa Requirements
o Reports feeling little relief of pain from burning rash.
❖ Patient denies taking any vitamin or supplements.
Allergies
Patient denies having any allergies to any food, medications, latex, or environment.
Pertinent Family History, Social History, and other subjective data if relevant
Mr. Barbosa denies having a family history of skin diseases but reports that his father has
high cholesterol and hypertension, and his mom has diabetes. Both parents are still alive, and he
has one brother with no health issues. Patient reports that he lives in a condo with his husband.
He reports being a firefighter and having a strong support group of family, friends, and colleagues at
the firehouse. Patient reports that he lost his best friend who was also a firefighter in the line of
duty in an accident. He reports that it has been hard and that he has started therapy for grief
counseling to help cope with the death of his friend. He denies using tobacco or any illicit drugs
and reports drinking alcohol 1-2 nights per night. He likes drinking one to two glasses of wine
with dinner.
ROS (Pertinent review of systems)
❖ General: Patient reports having more fatigue than usual, denies fever, chills,
and weakness
❖ Head- denies history of trauma, or headaches.
❖ Eyes- denies wearing glasses or contacts, and says vision is good.
❖ GI/GU- denies nausea, vomiting, abdominal pain, or diarrhea.
❖ Musculoskeletal- denies any joint pain, back surgery and reports no recent injuries.
❖ Neuro- denies any weakness, dizziness or any problems with memory or coordination.
Focused Integumentary SOAP Note- Felipe Barbosa Requirements
