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NU611 UNIT7 Soap Note

Subjective (S):

CC: chief complaint – “This rash is getting worse, even with the creams you gave me”.

HPI: history of present illness – Patient is an 11-year-old black female who presents with complaint of worsening rash on bilateral arms and increased itching and flakiness on her scalp.

PMH: past medical history – She has a past medical history of mild eczema with no prior treatment needed before this fall.  There is no reported history of asthma.

Allergies:   None

Medications:  Hydrocortisone topical cream 2.5% to be applied twice daily to affected area.

Social history: She lives at home with her mother, father, and younger brother.  She is currently attending online schooling due to the pandemic.  She has two cats as well in the home.

Family history: Mother reports that the patient’s younger brother also suffers from eczema and asthma, both are controlled.  She reports they have never had to treat her brother’s eczema and he uses a rescue inhaler for his asthma.

NU611 UNIT7 Soap Note

Health Maintenance/Promotion –

A screening of blood pressure is necessary yearly and was normal for this visit.  She received her influenza vaccine in October 2020.  The family has declined the HPV vaccine while they review education materials.  She is up to date on all other vaccinations.  Depression screening was performed at her last physical in October and she scored a zero.  She last saw her dentist about six months ago and goes twice a year.  She does not receive regular vision exams and does not report any vision concerns.  She denies any concerns of interpersonal violence or safety concerns in the home (this was asked while the mother was outside of the exam room).

ROS: review of systems –

General: She reports having a rash on her arms for the last month that is worsening.  She reports trying “the cream that was prescribed” with little to no improvement.  She also states that her scalp is itchy and flaking over the last month.  Her mother reports she has always had a flaky scalp in the colder months, but the itching is new.

Skin: She denies any new skin lesions, growths and hair or nail changes.  She reports that the “rash” that she has in the inside of her upper arm and some new “flaking” on her scalp. She denies noticing any skin changes to the skin on her neck.

NU611 UNIT7 Soap Note

HEENT: She denies any vision changes.  She denies any headaches.  She denies eye pain, hearing concerns (ringing), vertigo, dizziness, nosebleeds, or balance concerns.  She denies any ear pain, tinnitus, or drainage from her ears.  She reports that she always has dry scalp but now she is having increased flaking and itchiness on her head.

Neck: She denies any swollen glands or throat, difficulty swallowing or changes with range of motion in neck.

CV: She denies any palpitations, chest pain or feeling any abnormal heart beats.

Lungs: She denies any shortness of breath, congestion, or hemoptysis nor wheezing.  She denies any coughing at night or coughing that awakens her at night.

Endo: She denies any heat or cold intolerances noticed.  She and her mother deny any polyuria, polydipsia, or polyphagia.  She denies any history of any autoimmune disorders.

Diet: She reports that she eats almost anything.  She does drink “flavored water”, but it is zero calorie sweetener such as sucralose, according to her mother.  She reports drinking about 10 glasses of water a day.  She loves chips and eats a lot of “fast food”.  Mc Donald’s is her favorite.

NU611 UNIT7 Soap Note

Pain: She reports that the area of her arms is very itchy, they are also painful most of the time.  She reports the pain as a 7/10 and a burning feeling along with the severe itching.  She reports that nothing makes the pain better and the only things that feels better is when she itches. She reports that right after she itches then it starts to burn worse and itch more.  She reports this itching and burning starting “sometime in October”.  She reports that nothing makes it better.  She reports that scratching makes it worse, it burns more.  She says that putting on the cream makes it hurt worse (burn).

Objective (O):

Gen: Patient appears calm, focused, and a little tired.  She is dressed appropriately for the environment and responds appropriately to questions.  She is alert and oriented to person, place, and time.  She is well nourished and in no acute distress.

VS:

Weight 97 lbs.

Height 4 ft. 7in

BMI 22.5

Temperature 100.7

Heart rate 92

Respiratory rate 16

Blood pressure 101/68

Pulse Oximeter 100%

Skin: Patient had signs of excoriations on bilateral antecubital region.  She also had scaling on bilateral antecubital regions with erythema about 3 inches in diameter.  The arms appear xerotic bilaterally.  She has medium brown skin and no signs of cyanosis or pallor.  Nails appear intact and long with no signs of clubbing.  The neck had acanthosis nigricans circumferentially.

NU611 UNIT7 Soap Note

HEENT: The nose had no signs of erythema nor edema.  The nasal turbinates were pink in color and without edema bilaterally.  The exterior nose was symmetric.  The septum has no signs of deviation, inflammation, or perforation.  The mouth did not have any lesions.  The tonsils were inspected and were 2+ bilaterally, they were symmetric, and had no edema, and no exudate.   The uvula was inspected and was midline.  The dentition had no broken or missing teeth and gingiva was free of edema or lesions.  The posterior pharynx was free of lesions and no signs of drainage or irritation.  The frontal and maxillary sinuses were palpated, and no edema was noted nor any discomfort.  The tongue had no lesions nor edema and was symmetric.

The conjunctiva was free of drainage, discharge, or erythema.  The sclera had was not discolored and there were no vascular abnormalities noted. The ears were visualized externally with no drainage or edema.  The inner ears were visualized via otoscope and the ear drums were inspected and there were no effusions bilaterally, there were no ruptures, or draining fluid.  There was a moderate amount of cerumen blocking the visualization of the left ear drum, but this was easily removed to gain visualization.  The internal auditory canal was visualized without any edema, nor erythema and no foreign bodies were observed.  The preauricular and post auricular lymph nodes were not palpable.

NU611 UNIT7 Soap Note

Neck: The cervical, neck, mandibular, supraclavicular, tonsillar, and submental lymph nodes were not palpable, there was no edema nor tenderness noted on the tonsillar, cervical and neck.  The neck was visualized with no signs of asymmetry or JVD.  Full ROM was tested and there are no concerns of internal edema causing motor deficits.

CV: The heart sounds were auscultated in all areas, valve locations along were auscultated along with PMI, a normal S1 and S2 and no murmurs or abnormal heart beats were heard.  The heart rate and rhythm were normal.  Blood pressure and heart rate was assessed, and blood pressure was normal.

Lungs: Anterior and posterior lung fields were auscultated with all field being clear bilaterally.  Respiratory rate and rhythm were measured and normal.  Bilateral lung expansion was visualized.

Psych:  Patient was happy and talkative and was willing to answer questions and respond to my conversation with good eye contact and without difficulty.

NU611 UNIT7 Soap Note

Assessment (A):   

Number each diagnosis you assign AND list in parentheses behind the diagnosis the pertinent positives and pertinent negatives you used to assign the diagnosis

Guiding Questions:

Referrals or consult while in clinic with another provider.

If no referral made was there a possible referral you could make and why?

Names, dosages, and routes of administration along with indication of use.

State the offending medication/food and the reactions.

Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.

What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.