Soap Note Monday, September 6, 2010 7/27/10 1000 T.M. is a 9-yr-old black male Referral: None Source and Reliability: Self-referred with parent; seems reliable; report from patient and mother.
S-Subjective: Chief Complaint: Rash and itching on back and both arms for 1-2 months. Rash and itching on left knee for 2-3 months. Present Illness: Child reports that the area to his left knee started “a long time ago”. Mom thinks that it was 2-3 months ago and started as a small round, red area that has gotten larger over time and now appears whitish all over and covering the front of the child's knee. Mom and child note that the areas to his back and arms started about 1-2 months ago and are progressing like the area to the knee did. Child reports that all areas have itching almost all the time. Denies any drainage or pain at the areas. Denies aggravating or alleviating factors. Mom denies any treatment used because she did not know what to use. Past History: Allergies: Amoxicillin- rash Childhood Illnesses: None Medical: No asthma or recurrent bronchitis. Surgical: None Psychiatric: None Hospitalizations: None Health Maintenance: Immunizations up to date. Not exposed to second-hand smoke. Medications: None Family History: Mom denies family history of CAD, stroke, heart attack, asthma, cancer, thyroid disease, diabetes, mental illness, or skin disorders. Social History: Active in school and sports. Enjoys playing outside. Exercise: Did not assess Safety measures: Wears helmet when riding bicycle. Wears seatbelt in car.
REVIEW OF SYSTEMS
S - Subjective: Skin: “Red to whitish rash” and itching to left knee, back and arms. Head, Ears, Eyes, Nose, Throat (HEENT): Head: No history of head injury. Ears: Hearing appropriate. Denies vertigo, tinnitus. Eyes: Denies diplopia or blurred vision. Did not assess for last eye exam. Nose: Denies epistaxis. Denies change in sense of smell. Throat: Denies dysphagia or change in sense of taste. Good dentition. Did not assess for last dental exam. Neck: Denies hoarseness, thyroid or lymph node enlargement. Thorax and Lungs: Denies cough or SOB. No hemoptysis. Cardiovascular: Denies orthopnea, CP or syncope. Gastrointestinal: Appetite good. Denies NV/D. No jaundice, gallbladder or liver problems. No recent changes in bowel habits. Genitourinary: Denies frequency, dysuria, hematuria or flank pain. Musculoskeletal: Denies tenderness over joints or difficulty with ambulation.
Neurologic/Psychiatric: No history of depression or psychiatric conditions. Hematologic: Denies easy bleeding. No history of anemia Endocrine: Denies history of thyroid disease and diabetes. Sweating appropriate. Allergic/Immunologic: None
O-Objective: Physical Assessment: T.M. is a well nourished male, in no apparent distress. Smiling and interactive in conversation. Pleasant and cooperative. Hair and clothing neat in appearance. Vital Signs: Ht. 48in.; Wt. 76.8lb; HR 96; T 99 Oral; RR 16; BP 86/40. Skin: Pink, warm and dry. Nails without clubbing or cyanosis. Numerous lesions noted to back and upper arms ranging from 2-4cm in size and round to irregular in shape. Each lesion noted to have a slight red, raised border and a scaly center. Lesion to left knee covers the entire anterior aspect of the knee past the edges of the patella. Approximately 6x8cm and irregular in shape. Edges noted to be slightly red and raised with a scaly center. No drainage, warmth, erythema or signs of secondary infections. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Skull is normocephalic, with injury. Hair with average texture. Ears: Correct response to whispered voice at 3 feet away. TMs intact. Cone of light noted. Hearing appropriate to conversation. Eyes: Sclera white with conjunctiva pink and moist; PERRLA at 3mm; Did not assess optic disc. Nose: Nasal mucosa pink and moist. Nasal turbinates without edema, no obstruction, septum midline. Throat: Oral mucosa pink and moist. Tongue midline. No dental caries or gingivitis. Neck: Trachea midline. No tenderness or masses. No thyromegaly. No lymphadenopathy. Thorax and Lungs: Thorax symmetric with good expansion. Lungs resonant. Breath sounds vesicular. No adventitious sounds. No hemoptysis. Did not measure diaphragm excursion. Cardiovascular: No JVD. Heart sounds S1, S2 with no murmurs, rubs or gallops. Musculoskeletal: Active ROM x 4 extremities. No pain noted on palpation of left knee. Peripheral vascular: Sensation intact. Capillary refill <3 seconds. Neurologic/Psychiatric: Alert and oriented to person and time. Cooperative and pleasant. Interacts in visit. No gross focal, motor or sensory deficits. Lab work obtained: None
Procedures: None
A-Assessment/Diagnoses 1. Health Maintenance: Immunizations 2. Self-limiting problems: Tinea Corporis (110.5) DD: Psoriasis (696); Contact dermatitis (692); Bacterial infection (041.9) 3. Chronic Health Problems: None
P-Plan 1. Health Maintenance: Immunizations up to date. 2. Self-limiting problems: 1. Diflucan 150mg PO x 1 now and repeat in one week; #2; No refills. 2. Selsun Blue apply daily x 1 week to affected areas for 2-3 minutes then rinse the areas and pat dry. Repeat the process once a month for 3 months. Do not apply to inflammed skin. If skin becomes inflammed, stop the applications and contact PCP. 3. Keep skin dry. This is a fungal infection and fungus likes to grow in warm, moist places. 4. Wash hands after handling animals, soil and plants. 5. Keep lesions covered until healed and avoid touching similar lesions on other people because this infection is contagious. 6. Practice good hygiene when involved in contact sports. 7. Follow-up with PCP as needed for worsening symptoms or if current treatment is not successful to treat the condition. 3. Chronic Health Problems: None
Christy Holshouser RN, UASON FNP student Christy Holshouser RN, FNP student Sources: McPhee, Stephen J. and Papadakis, Maxine A (2010). Current medical diagnosis and treatment. New York, NY: McGraw Hill. Ferri, F. (2010). Ferri’s Clinical Advisor 5 Books in 1. Philadelphia, PA: Mosby/Elsevier Epocrates Dx: [database for PDA]. Version 3.4. San Mateo (CA): Epocrates, Inc. c2010 [updated 2010 May 23; cited 2010 Jun 10]. Available from http://www.epocrates.com