Running Note: SOAP NOTE: HERPES SIMPLEX VIRUS TYPE 1 1
SOAP Note: Herpes simplex virus type 1
Identifying Data and Chief Complain
A 22yearold female, Puerto Rican, and single, comes to the clinic complaining of
“painful blisters on the upper lip and surrounding skin”. She states, “It started five days ago with
tingling on the upper lip. I woke up two days after with some blisters on the upper lip, but it has
spread to the surrounding area and now it looks very ugly, redness, swollen and it hurts a lot. I
have not attended college since yesterday, because I do not want people to see me with this”.
Her medical insurance is MCS and her father is the primary cardholder.
Subjective Symptoms
1. “tingling on the upper lip”
2. “painful blisters in the upper lip and surrounding skin”
3. “it looks very ugly, redness, swollen and it hurts a lot”
Subjective Data
Past medical history (PMH): Patient informs that she had a healthy childhood. Menarche was
at 11 years old. LMP: April 16, 2016. Patient states that she is not sexually active at this
moment. She denies chronic diseases. Last Pap Test was in January 2016- negative.
Immunizations are up to date, including Gardasil. Patient refuses influenza vaccine.
Family history: Her mother is a 43-year-old woman with no history of chronic diseases. Her
father is a 46-year-old man with HTN. She has a 17-year-old healthy brother. Her grandfather
from the father’s side is a 66-year-old man with DM2 and HTN. Her grandmother from the
father’s side is a 65-year-old woman with hyperthyroidism. Her grandfather from the mother’s
side died 4 years ago at 68-year-old from a MI and her grandmother from the mother’s side is a
69-year-old woman with rheumatoid arthritis and osteoporosis.
, SOAP NOTE: HERPES SIMPLEX VIRUS TYPE 1 2
Past social history (PSH): Patient refers no toxic habits in the past and present time. She is
single. She is Catholic. She is not sexually active, but has started a relationship recently. Patient
lives with her parents in their own house. She studies the last year of criminal justice and plays
volleyball in the university team. She informs that exercise and train every day.
Immunization: Up to date, including Gardasil. Patient refuses influenza vaccine.
Allergies: No known allergies (NKA).
Surgical history: No surgeries history.
Medication history: No history of prescribed medication. She takes a multivitamin daily.
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Patient denies weight changes. She refers pain in the upper lip.
Skin: She reports blisters, swelling, redness and pain in the upper lip and surrounding skin, but
denies acne, dry skin, pruritus, no nodules, no new moles, no dry hair and no eczema.
HEENT: Patient indicates no hear difficulty or tinnitus, no congestion, no dental or swallowing
problems and no vision problems and no use of eyeglasses.
Respiratory: Patient denies rhinitis, dyspnea, hemoptysis, cough or secretions.
Cardiovascular: Patient denies tachycardia, bradycardia, palpitations, orthopnea or chest pain.
Gastrointestinal: Patient denies abdominal pain, has normal bowel movements and no changes
in elimination frequency or consistency, no indigestion or heartburn.
Genitourinary: Patient denies pain or burning during urination, no genital lesions, hematuria or
discharges. Neither STDs. She is not sexually active.
Musculoskeletal: Patient denies myalgia, weakness, difficult to walk, fractures or cramps. No
pain or fluid retention in hands, legs or feet.
Neurologic: Patient denies dizziness, migraines, disorientation, involuntary movements,
numbness, tingling, anxiety or depression.
SOAP Note: Herpes simplex virus type 1
Identifying Data and Chief Complain
A 22yearold female, Puerto Rican, and single, comes to the clinic complaining of
“painful blisters on the upper lip and surrounding skin”. She states, “It started five days ago with
tingling on the upper lip. I woke up two days after with some blisters on the upper lip, but it has
spread to the surrounding area and now it looks very ugly, redness, swollen and it hurts a lot. I
have not attended college since yesterday, because I do not want people to see me with this”.
Her medical insurance is MCS and her father is the primary cardholder.
Subjective Symptoms
1. “tingling on the upper lip”
2. “painful blisters in the upper lip and surrounding skin”
3. “it looks very ugly, redness, swollen and it hurts a lot”
Subjective Data
Past medical history (PMH): Patient informs that she had a healthy childhood. Menarche was
at 11 years old. LMP: April 16, 2016. Patient states that she is not sexually active at this
moment. She denies chronic diseases. Last Pap Test was in January 2016- negative.
Immunizations are up to date, including Gardasil. Patient refuses influenza vaccine.
Family history: Her mother is a 43-year-old woman with no history of chronic diseases. Her
father is a 46-year-old man with HTN. She has a 17-year-old healthy brother. Her grandfather
from the father’s side is a 66-year-old man with DM2 and HTN. Her grandmother from the
father’s side is a 65-year-old woman with hyperthyroidism. Her grandfather from the mother’s
side died 4 years ago at 68-year-old from a MI and her grandmother from the mother’s side is a
69-year-old woman with rheumatoid arthritis and osteoporosis.
, SOAP NOTE: HERPES SIMPLEX VIRUS TYPE 1 2
Past social history (PSH): Patient refers no toxic habits in the past and present time. She is
single. She is Catholic. She is not sexually active, but has started a relationship recently. Patient
lives with her parents in their own house. She studies the last year of criminal justice and plays
volleyball in the university team. She informs that exercise and train every day.
Immunization: Up to date, including Gardasil. Patient refuses influenza vaccine.
Allergies: No known allergies (NKA).
Surgical history: No surgeries history.
Medication history: No history of prescribed medication. She takes a multivitamin daily.
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Patient denies weight changes. She refers pain in the upper lip.
Skin: She reports blisters, swelling, redness and pain in the upper lip and surrounding skin, but
denies acne, dry skin, pruritus, no nodules, no new moles, no dry hair and no eczema.
HEENT: Patient indicates no hear difficulty or tinnitus, no congestion, no dental or swallowing
problems and no vision problems and no use of eyeglasses.
Respiratory: Patient denies rhinitis, dyspnea, hemoptysis, cough or secretions.
Cardiovascular: Patient denies tachycardia, bradycardia, palpitations, orthopnea or chest pain.
Gastrointestinal: Patient denies abdominal pain, has normal bowel movements and no changes
in elimination frequency or consistency, no indigestion or heartburn.
Genitourinary: Patient denies pain or burning during urination, no genital lesions, hematuria or
discharges. Neither STDs. She is not sexually active.
Musculoskeletal: Patient denies myalgia, weakness, difficult to walk, fractures or cramps. No
pain or fluid retention in hands, legs or feet.
Neurologic: Patient denies dizziness, migraines, disorientation, involuntary movements,
numbness, tingling, anxiety or depression.
