Running head: EPISODIC SOAP NOTE: TOM WALKER 1
Episodic SOAP Note: Tom Walker
Lee Arthur
NRP 531
Professor Sandra Brown
, 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
Episodic SOAP Note: Tom Walker
Lee Arthur
NRP 531
Professor Sandra Brown
, 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
