Dermatology SOAP Note Sample Report #1
SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in today for a skin check. He has had two melanomas in the past; one with a Clark level IV 4.9 mm melanoma on his left arm. There were five mitoses per square millimeter with no ulceration. This was excised on MM/DD/YYYY with a negative sentinel lymph node biopsy.
On MM/DD/YYYY, he had another lesion distal to this on his left wrist that was removed and was shown to be a 1.4 mm thick melanoma, level IV, less than one mitoses per square millimeters with ulceration absent.
Of note, for the second melanoma, there was a question of epidermotropic metastasis; however, there was an in situ component to this suggesting a primary lesion but could not completely rule out epidermotropic metastasis on the pathology report. This was re-excised with a negative sentinel lymph node biopsy.
He currently notes that he is doing well with no new or changing moles. He does point to a wart on his third finger of his left hand that he has had for quite some time. He also has one on the right finger web between the first and second digit as well.
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. Wart: On his third finger on his left hand, he had a 3-4 mm hyperkeratotic papule and this was frozen with liquid nitrogen with three brief freeze-thaw cycles. On the next visit, we will freeze it a bit harder if it appears to persist and he did not get too much of an inflammatory response; and also, on his right finger web, he had a 3 mm papule that was frozen with liquid nitrogen as well.
2. History of melanoma x2: He had on his left forearm and left wrist two well-healed scar sites with no evidence of pigmentation or nodularity in or around the scar sites; as usual amelanotic. He will watch for pink lesions that are persistent, and he will continue self-skin checks.
3. Nevi: He had relatively few brown macules and papules scattered on torso and extremities but nothing concerning for malignancy.
We will see him back in one month to treat his warts if it is still present and in three months for his next skin check.
Dermatology SOAP Note Sample Report #2
SUBJECTIVE: This is a patient who has borderline tuberculoid leprosy diagnosed in December YYYY. He completed triple therapy in December YYYY. He restarted clofazimine 50 mg daily for neuritis and he is still taking that. He is also on prednisone 5 mg daily for neuritis.
He had a gangrenous ulcer of the left foot with amputation of the left toes and forefoot in YYYY. He has had recurrent infections of that same stump. He complains that the shoe he wears, which is a custom-made shoe, rubs on the anterior aspect of the left foot stump, which causes ulceration and blister. He is due to see the orthopedic shoe makers today for evaluation of his shoe and possible alteration to the shoe itself.
OBJECTIVE: This is a (XX)-year-old gentleman, who is awake, alert and oriented x3, in no acute distress, with normal mood and affect. Examination was limited to the left foot. On the anterior aspect of the left foot, he does have a well-healed amputation site, which is pink with some mild overlying callus. No evidence of infection. No discharge or foul odor.
ASSESSMENT AND PLAN: History of borderline tuberculoid leprosy, which has been treated with triple therapy completed in December YYYY. He is still on clofazimine 50 mg daily. Continue clofazimine and prednisone as needed for neuritis. Today, he will have an appointment with the shoe makers and possibly get a new shoe made. He will follow up at the next clinic.
Dermatology SOAP Note Sample Report #3
SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for a skin check. I saw her last on MM/DD/YY. She had a melanoma on her lower back diagnosed in MM/DD/YY that was 1.6 mm Clark level IV with negative sentinel lymph node biopsy. Prior to that, she also had breast cancer. She is 18 years out from that and doing quite well. She has had actinic keratoses in the past as well as numerous basal cell skin cancers. She had a most recent basal cell skin cancer on the left upper shoulder that was removed with excision on MM/DD/YYYY. She has one spot on left forehead that is pink that she points out today and also a spot that is whitish-yellowish under her left eye that she points out. She has no new or changing moles she is concerned about.
OBJECTIVE: Well-appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.
ASSESSMENT AND PLAN:
1. Status post melanoma: On her lower back, she has a well-healed scar site in the area of the prior melanoma without any pigmentation or nodularity in or near the scar site. She will continue self-skin checks.
2. Status post basal cell skin cancer: She had a well-healed scar on her left upper shoulder in the area of the prior basal cell skin cancer without any evidence of recurrence. We discussed she has a continual risk for new basal cell skin cancers as well as melanomas given her past history of these and past sun damage. She does a good job protecting herself from the sun now and does take vitamin D supplementation.
3. Nevi: She had relatively few brown macules and papules scattered on torso and extremities with nothing concerning for malignancy.
We will see her back in six months.
Dermatology SOAP Note Sample Report #4
SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for followup of a biopsy site on her right thigh that was biopsied with a 6 mm punch by Jane Doe on MM/DD/YY. She felt it was infected, and by phone, she was given mupirocin ointment that she has been using on it, and she states she no longer sees any pus in it and she thinks it is getting improved.
OBJECTIVE: Well-appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the right thigh. On the right thigh, she had two sutures intact on a slightly erythematous base. We do not see any evidence of pus and it does appear a little bit erythematous, but I think the mupirocin is helping.
ASSESSMENT AND PLAN: We did discuss, if things were to get worse such as her seeing pus again or the redness increasing, to let us know and she might need to start an oral antibiotic, but from what we see today, we think the mupirocin would be enough to continue treating the area. The sutures were removed since it has been 12 days since the surgery and she is informed that the lesion was a benign mole and not concerning.
