Medical Case Proofreading Exercise

Satisfactory Essays
PROOFREADING EXERCISE #11

QUALI0CARE CLINIC SOAP NOTE

Patient Name: Joann Barnett PCP: David S. Duke, MD

Date of Birth: 02/08/2012 Age: 27 Sex: Female

Date of Exam: 12/03/2012

SUBJECTIVE: This is a pleasant 27-year-old white female who is new to the practice. She presents today for a couple of medications. She was given a script for Patanol by her eye doctor to help with some allergic conjunctivitis issues. She also has been prescribed Metrogel by her dermatologist for acne rosacea. She denies any acute concerns at this time. Patient is due for her annual healthcare maintenance and gynecologic care after the first of the year. She is going to have records from her other providers sent here. She is on no other medications at this time. Denies any known medication allergies. She is currently a nonsmoker, quit five years ago. No ETOH and no elicit drug exposure. Denies significant chronic medical problems. Patient does have an aura on her left arm that she would like looked at by a dermatologist, and she would like a referral to be evaluated by Dermatology here. She describes a small mold that has been present for quite some time and may be increasing slight in size.

OBJECTIVE: Patient appears as a well-developed female in no specific distress. Blood pressure 134/86, pulse 85, weight 168 pounds. Focused examination of the right arm reveals a small, circular lesion on the anterior forearm, most consistent with a seborrheic keratosis. This is pigmented and is popular.

ASSESSMENT: Patient is a 27-year-old white female with a history of acne rosacea, followed by Dermatology. She has a script for Metrogel that she would like to have filed. She feels that controls things well. She would like to continue care with Dermatology here. She has a pigmented legion on her left forearm, most consistent with a seborrheic keratosis. She would like to have this evaluated for possible excision. She will be establishing primary

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