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SOAP note

Ms.Sawanit Suwannaraj KKU

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Patient profile

22 160 cm CC: 5- 6

( 1 )H PI: PM H : -

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S : 5- 6

1 ALL: noSH: no drinking, no smokingO : -

Problem list: : Recurrent herpeslabialis (recurrent facial-oral herpes

simplex)

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AssessmentEtiology; he rp e s simpl ex virus (HSV) 2

HSV- 1

HSV- 2 (facial -oral he rp e s simpl ex )

1. Primary facial-oral herpes simplex

Neonatal herpes simplex Acute herpetic gingiostomatitis

2. Recurrent facial-oral herpes simplex cold sore

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D evelopment stages of recurrent H SV-1

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Factors known to activate recurrent H SV

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Assessment

D iagnosis : re curr e nt facial -oral he rp e s simpl ex

Assessment of Therapy; F rom R e curr e nt

He rp e s Labialis A se ssm e nt and Non -pr e scription Tr e atm e nt of M e diRe sourc e , Jam e sPat e rson non -pr e scription t he rapy

pr e scription t he rapy

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1. non

-pr

escription t

herapy

- : skin prot e ctant / - : Z inc,He parin, Lipactin Docosanol A br e vaTM

. . 2 549 (List of H e rbalMe dicinal Products A .D.2006 )

Assessment therapy

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N on-prescription therapy

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Assessment therapy

2 .pr e scription t he rapy A cyclovir, Famciclovir, Valacyclovir

2 A cut e the rapySuppr e ss t he rapy

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Summary of evidence-

basedmanagement

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Prescription therapy

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acyclovir cream

2

2

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Summary of evidence-based

management

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G oal : - re lie f pain, burn, and irritat e from l e sion- C h ang e beh avior

Therapeutic Plan :

Rx M-Zavir 5% acyclovir cream 1 tub eapply e ve ry 2 h r for 5 days.

5 sac he ts

7 tab x 3 pc for 5 days

Plan

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Monitoring plan :The rap e utic Monitoring : improv e symptom obs e rve from l e sion

A DRs/To x ic Monitoring :

M-Zavir 5% acyclovir cr e am : n/v, skin ras h , itc h ing

Education Plan : advic e about b eh avior c h ang e , and control dis e as e

Future Plan : If the me dication do e s not e ff e ctive >> advic e doctor to c h ang e the rapyIf A DR occur >> stop t he the rapy and advic e the doctor to consid e ralt e rnativ e the rapy

Plan

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