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S.O.A.P. Note Template
Case ID# : S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan)
Basic Information
Pediatric Clinic Sick Visit 9/5/ O.F. Assignment 2.
Subjective History
Chief Complaint
Skin problems/Rash
History of Present Illness
Reported by parent. Location: face; chest; abdomen; back; arms; legs Quality: not itchy; not painful Severity: moderate Onset/Timing: 3days ago Context: no contacts with similar symptoms; no recent travel; no contacts who have traveled recently; new detergent or skin product; mom switched to a natural and organic laundry detergent Mom states she noticed a rash all over pt body 3 days ago. Mom states she changed to an organic laundry detergent. mom states pt has also when teething so she is wondering if its that because it is better now.
Past Medical History
Insignificant NKDA Surgeries include circumcision neonate 8/ No medications
Family History
Paternal Grandfather-depressive disorder, ADHD Maternal Grandmother-Disorder of the thyroid gland, arthritis, migraine, osteoporosis, epilepsy Mother-Allergy, ADHD, Epilepsy Brother-Epilepsy Sister-Asthma
Personal/Social History
Home and Environment What is your home situation?: Both parents Have there been any changes to your family or social situation?: No Do you have any siblings?: No Do you have any pets?: Yes Do you have smoke and carbon monoxide detectors in your home?: No Are you passively exposed to smoke?: No Are there any guns present in your home?: No What is the fluoride status of your home?: Unknown Do you use insect repellent routinely?: No Do you use sunscreen routinely?: No Marriage and Sexuality What is your parents' marital status?: Unmarried Activities of Daily Living Are you blind or do you have difficulty seeing?: No Are you deaf or do you have serious difficulty hearing? : No Do you have difficulty concentrating, remembering or making decisions?: No Advance Directive Is blood transfusion acceptable in an emergency?: Yes Lifestyle Do you use your seat belt or car seat routinely?: Yes Diet and Exercise What type of diet are you following?: Regular What is your exercise level?: Moderate
Diagnostic Testing/Findings (if appropriate) Assessment Primary diagnosis: Viral Exanthem Differential Diagnosis: Scarlet Fever, Rubella Plan/Education
- Continue to monitor and call with any questions or concerns.
- Follow up at next well child check up, sooner if needed.
- Keep skin clean and dry.
- Contact office immedtiately if patient develops high fever, facial swelling, mucosal symptoms, skin tenderness, development of pustules or blisters, or jaundice. References Characterizing viral exanthems. (2011, January 31). Medscape. Retrieved September 5, 2023, from HYPERLINK "https://www.medscape.com/viewarticle/734882_2"https://www.medscape.com/ viewarticle/734882_ Khandpur, S., & Ahuja, R. (2022). Drug-induced vs. viral maculopapular exanthem— resolving the dilemma. Dermatopathology, 9(2), 164–171. HYPERLINK "https://doi.org/10.3390/dermatopathology9020021"https://doi.org/10.3390/ dermatopathology
