SOAP note: Using this template, complete one SOAP note from a patient in your current NSG6440 clinical experience. The completed note should be submitted to the Submissions Area.
SOAP NOTE
| Name: JR | Date: 08/05/2020 | Time: 2:00pm |
| Age: 62 | Sex: Female | |
| SUBJECTIVE | ||
| CC: “I have a rash and itching around my neck and face” | ||
| HPI: (Use OLDCART)The patient states that she has had relapsing itching and rash for the past 30 years. She has controlled the rash with medication and always attributed it to allergies, but now she wants to cure it. The rash is reddish, and brown around the neck, and red around the face. It is described as a faded red rash with small red dots. It causes itching at all times of the day. The patient states that she has had it for around 30 years, but she does not remember exactly. She uses an over the counter anti-itch cream and applies it to the area twice a day. This alleviates the itching associated with the rash. | ||
| Medications: (list with reason for med)Hydrocortisone cream applied to the affected area twice daily. (Rash)Multivitamin 1 cap daily. | ||
| PMHAllergies: NKDA, allergic to pollen, and dust (sneezing, rhinitis)Medication Intolerances: DeniesChronic Illnesses/Major traumas: Left Clavicle fracture (1980)Hospitalizations/Surgeries: Left clavicle fracture repair (1980) | ||
| Family HistoryMother- deceased from natural causes at age 89Father- deceased from lung cancer at age 93No SiblingsNo children | ||
| Social HistoryGeneral: Born in Miami, and has lived here her whole life.Marital status: Married for the past 37 years, lives with her husband.Living situation: Patient lives with her husband in a home in Miami. Has friends living in the same area. Financial situation is comfortable.Children: NoneOccupation: Owns several real estate properties.Leisure Patterns: Patient goes out with her husband to restaurants and events with their friends often. She wants to begin travelling as well.Social habits: Practices yoga in the outdoors 5 times a week. Does not drink, does not smoke.Spirituality: No religious involvement.Nutrition: Patient states that she eats healthy and focuses on low-carb meals with an emphasis on protein.Sleep Patterns: States that her sleeping habits are normal, and she sleep around 9 hours a day. | ||
| ROS | ||
| GeneralRash has been present for the past 30 years with no changes.Head: Denies headache, head injury, dizziness, or lightheadedness. | CardiovascularDenies any troubles with her heart, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort. | |
| SkinReports skin rash present around her face and neck for the past 30 years. Reports itching and redness. Denies blood or pus from the skin. Reports dryness. | RespiratoryDenies cough, sputum, hemoptysis, dyspnea, wheezing, or pleurisy. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis. | |
| EyesNon-contributory | GastrointestinalNon-contributory | |
| EarsNon-contributory | Genitourinary/GynecologicalDenies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.Menarche at age 14. Menopause at the age of 52. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G0P0. Denies use of birth control methods. Sexually active at the moment. Has had one partner for the past 40 years. Denies exposure to HIV infection or STDs. No hx of pap smear. | |
| Nose/Mouth/ThroatReports allergies to dust and pollen that cause rhinitis, and runny nose.Neck: Reports reddish, brown rash in the neck area. | MusculoskeletalNon-contributory | |
| BreastNon-contributory | NeurologicalNon-contributory. | |
| Heme/Lymph/EndoNon-contributoryPeripheral Vascular: Non-contributory | PsychiatricDenies nervousness, tension, mood changes, depression, or memory changes. | |
| OBJECTIVE | ||
| Weight 115 lbs. BMI 17.5 | Temp 97.8 F | BP 129/65 |
| Height 68” | Pulse 76 | Resp 15 |
| General AppearancePatient alert and oriented x3. In no signs of acute distress. | ||
| SkinSkin around the mouth and nose area is reddish in coloration without any signs of bleeding or lesions. No signs of pus or infectious papules. Skin area around the neck is dry, reddish and has a slight brown coloration. No signs of infection, blood, or pus. Skin in both areas is dry. | ||
| HEENTNormocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits. | ||
| CardiovascularCarotid upstrokes are brisk, w/o bruits. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. | ||
| RespiratoryThorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. | ||
| GastrointestinalDeferred | ||
| BreastDeferred | ||
| GenitourinaryDeferred | ||
| MusculoskeletalDeferred | ||
| NeurologicalDeferred | ||
| PsychiatricAlert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time. | ||
| Lab TestsCBC, CMP, Lipid Panel, Serum Ig E. | ||
| Special TestsNone | ||
| Diagnosis | ||
| Diagnosis:1. Atopic dermatitis (L20)· The most likely diagnosis is atopic dermatitis, also known as eczema. It is marked by a long history of skin rash characterized by itching, and redness. In adults it may also manifest as a reddish-brown ring around the neck (Silvestre Salvador, Romero-Perez, & Encabo-Duran, 2017). The patient has had this rash for a very long time, and a history of recurrent rash is indicative of atopic dermatitis.Differentials:1. Allergic contact dermatitis (L23.9): The patient states that she suffers from seasonal allergies including pollen and dust. She also states that she practices yoga outside at least 5 times a week. Contact with an allergen may be the cause of her dermatitis.2. Irritant contact dermatitis (L24.9): An unknown irritant such as a household cleaner, or perfume may also be the cause of this patient’s dermatitis.3. Immunodeficiency (D84.9): According to the Immune Deficiency Foundation, eczema or contact dermatitis is a very common results of primary immunodeficiency diseases (Autoimmunity, n.d.). | ||
| Plan/Therapeutics | ||
| Plan: Diagnostic: Pending lab results.Plan/TreatmentPharmacologic:Patient will be sent a corticosteroid cream for the itchiness. A 1% Hydrocortisone cream may be purchased over the counter. Apply to the area twice a day.Non-pharmacologic:· Bath once daily with warm water. Do not use hot water.· Apply soap only to dirty areas, and use a mild cleanser· After bathing and drying, apply a moisturizer to the affecter dry areas. Use creams and not ointments.· Monitory closely the effect of allergens and potential irritants on the rash. Try to identify any potential allergens that may cause exacerbations.· Educate patient to avoid activities that cause excessive sweating and swimming in an outdoor pool.Referral: None at this time.Follow-Up: Follow up with the patient in 2 weeks to review lab results, to rule out any concurrent illnesses that may cause rash. We will discuss further treatment and diagnostic options such as patch testing in the follow-up visit. | ||
| Evaluation of patient encounter:I contributed about 40% of this patient encounter. I conducted the physical exam, whilst my preceptor discussed treatment options, and patient education.Weaknesses: It was very hard for me to come up with diagnoses for this case, because a rash is a common occurrence in many illnesses.Strengths: I conducted the physical exam with ease, and my preceptor praised me afterwards.Reflection: I am improving significantly in the time it takes me to conduct a physical examination. It was very difficult for me at first but then it became easier. |
References:
Autoimmunity. (n.d.). Retrieved from Immune Deficiency Foundation: https://primaryimmune.org/about-primary-immunodeficiencies/relevant-info/autoimmunity
Silvestre Salvador, J., Romero-Perez, D., & Encabo-Duran, B. (2017). Atopic Dermatitis in Adults: A Diagnostic Challenge. Journal of Investigational Allergology and Clinical Immunology, 27(2), 78-88.
