Comprehensive SOAP Template
Patient Initials: J.R Age: 8 years Gender: Male
Chief Complaint (CC): Rash on the face, arms, and trunk accompanied by itching. (Fig 9.80 Ball et al., 2019).
History of Present Illness (HPI): J.R is an 8-year-old Caucasian patient presented with complaints of a pruritic rash. The patient’s caregiver reports that the rash appeared two days ago when the child was in school. The rash first appeared on the scalp and the face and progressed to upper limbs and the trunk on the same day. The mother states that the rash started as small red spots, which rapidly progressed to small clear pimples with a surrounding reddish area within 12 hours. The caregiver reports that this is the first episode that the child developed the characteristic rash. She states that the child has had a mild increase in body temperature, is inactive, and has a decreased appetite. The patient states that scratching the rash triggers pruritus in his entire body. The caregiver reports that she had administered the child with Chlortrimeton syrup to lower the fever and reduce the itchiness, which had a moderate impact on the pruritus but did not control the spread and appearance of the rash. The patient denies any history of insect bite. However, the child reports that a classmate had developed a similar rash two weeks ago.
Medications: OTC Chlortrimeton syrup 10 mL three times a day.
Allergies: No known food, drug, or environmental allergies.
Past Medical History (PMH): J.R. had a history of hospitalization at the age of 3 years due to severe pneumonia, which was managed with IV antibiotics and oxygen therapy. No history of chronic illnesses.
Past Surgical History (PSH): The patient had a minor surgery, Incision, and Drainage, in Sep-2019 due to an abscess on his right thigh.
Sexual/Reproductive History: The patient is sexually inactive.
Personal/Social History: J.R. lives with his parents and two siblings in Salt Lake City, Utah. He is in 3rd grade and has a great academic performance. He states that his favorite subjects are science and art. He enjoys drawing and painting and is part of the Art club in school. The patient also states that he enjoys watching animation movies and playing video games when indoors. The mother reports that the child has no difficulties in performing ADL’s. The patient has an active lifestyle and enjoys playing soccer and swimming. He plays soccer in school and is part of the junior soccer team. He takes three meals a day with snacks between meals. The mother reports that he provides the child with a balanced diet with plenty of fruits, real fruit juices, and milk. The patient reports no eating difficulties. He sleeps approximately 10 hours a day and denies having sleeping difficulties.
Immunization History: The patient’s vaccination history is up-to-date. The last Influenza shot was 4 months ago.
Significant Family History: Maternal grandmother died at the age of 79 due to Lung cancer. The paternal grandfather has Hypertension and Type 2 Diabetes. Parents are alive and well. The elder sibling, 13-year-old, has Eczema.
J.R.’s mother denies engaging in any cultural practices or using herbs. The patient is economically supported by his father and mother. The father is an accountant while the mother is a high school teacher. The mother reports that she controls TV-time and supervises what the child watches on T.V. J.R. reports that he puts on protective gear when swimming and playing soccer. He also states that he has several friends, both from school and the neighborhood.
Review of Systems:
General: Genera body malaise and low-grade fever. Denies recent weight changes
HEENT: Head: Denies a history of headache. Eyes: Denies changes in vision, eye reddening, photophobia, or excessive lacrimation. The last eye-checkup 2 years ago, no abnormalities detected. Ear: Denies hearing loss, ear discharge, or pain behind the ear. Nose: Denies nasal discharge, epistaxis, facial tenderness, or history of allergic rhinitis. Reports an intact sense of smell. Throat: Denies dental pain, bleeding gums, or tongue soreness. Denies difficulties in swallowing, sore throat, or hoarseness.
Neck: Denies neck pain or stiffness.
Breasts: Denies breast mass or tenderness.
Respiratory: Denies cough, sputum production, shortness of breath, exertional dyspnea, or wheezing. History of Severe pneumonia 2015.
Cardiovascular/Peripheral Vascular: Denies edema, chest pain, palpitations, shortness of breath, exertional dyspnea, or bluish discoloration of lips or fingers.
Gastrointestinal: Denies experiencing nausea, vomiting, abdominal discomfort, or changes in elimination pattern.
Genitourinary: Denies urinary frequency, urgency, dysuria, or blood in the urine. Denies penile discharge.
Musculoskeletal: Denies difficulties in movement, muscle pain, joint pain, or joint stiffness.
Psychiatric: No history of anxiety, depression, or child conduct disorders.
Neurological: Denies history of headache, dizziness, syncope, seizures, tingling sensations, muscle weakness, or gait/posture abnormalities.
Skin: Pruritic red rash (refer to HPI).
Hematologic: No history of blood transfusion.
Endocrine: Denies cold/heat intolerance, acute thirst, increased hunger, or excessive sweating.
Allergic/Immunologic: No history of allergic reactions.
Vital signs: Ht.- 2’6, Wt.- 52.9 pounds RR- 18, HR-94, BP-104/65, and Temp- 99.86F
General: Patient is sick-looking with no acute distress. Maintains and upright posture. Neat and well-groomed. Patient is Alert and maintains eye-contact.
HEENT: Head is Normocephalic and symmetrical. The sclera is white and conjunctiva pink.
PERRLA, Tympanic membranes intact. Nasal septum well-aligned. Mucous membranes pink and moist. The tongue is midline; 2 missing teeth. Tonsillar glands non-inflamed.
Neck: Trachea midline, No Thyroid gland enlargement.
Chest/Lungs: Chest rise and falls uniformly on breathing in and out. Respirations smooth with no use of accessory muscles. Chest clear on auscultation.
Heart/Peripheral Vascular: No JVD or edema. RRR with no murmurs, friction rubs or
S gallop. Pulses+2 bilateral pedal and +2 radial
Abdomen: Flat and smooth. BS-normoactive in all quadrants. No tenderness, masses, or organomegaly on palpation.
Genital/Rectal: Normal male genitalia. No anal fissures or tears present.
Musculoskeletal: Muscle strength 5/5
Neurological: CNs-intact, DTRs-intact
Skin: Papular and vesicular lesions present on the scalp, face, upper extremities, and trunk. The lesions are elevated and circumscribed on the superficial layer of the skin. The skin around the vesicles is erythematous. The erythematous Lesions are filled with clear fluid and are < 1 cm in diameter and appear in clusters (Fig 9.80 Ball et al., 2019).
Chickenpox: Chickenpox, also known as Varicella, is an acute and highly communicable disease common in children and young adults. It is caused by the varicella-zoster virus (VZV) (Ball et al., 2019). The VZV is spread by droplets from the upper respiratory tract or discharges of ruptured lesions on the skin (Kennedy & Gershon, 2018). It has an incubation period of 14 – 21 days. It has a communicability period of 1 to 2 days before the onset of the rash and until lesions have crusted over.
Varicella results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the scalp and then spreads to the face, chest, back, and upper extremities (Ball et al., 2019). It begins with small, erythematous macules that rapidly progress over 12-14 hours to papules and then clear vesicles (Gershon et al., 2015). The vesicular stage is often accompanied by intense pruritus.
The skin rash is accompanied by low-grade fever, fatigue, pharyngitis, and headaches, lasting five to seven days (Gershon et al., 2015). However, childhood varicella does not begin with a prodromal phase but starts with the onset of exanthema.
Chickenpox is the priority diagnosis based on pertinent positive findings of red spots that progressed into erythematous vesicles and pruritus. Besides, a history of rash on the scalp and face and spread to upper extremities and trunk. Other positive findings include a low-grade fever, general malaise, and loss of appetite.
Nun-bullous Impetigo: Impetigo is a common and highly contagious, superficial skin infection that manifests with either a bullous or non-bullous appearance (Hartman-Adams, Banvard & Juckett, 2014). Non-bullous impetigo on children begins as a single lesion typically presenting as a red macule or papule. This quickly progresses into a vesicle. The vesicle ruptures, causing erosion and the vesicular contents dry to form a characteristic honey-colored crust (Ball et al., 2019). The non-bullous impetigo commonly occurs on the face or extremities. Individuals often have mild regional lymphadenopathy, but pharyngitis is absent (Hartman-Adams, Banvard & Juckett, 2014).
Nun-bullous impetigo is a differential diagnosis based on a positive history of the appearance of small red spots, which quickly progressed to vesicles within 12 hours. However, the presence of fever, erythematous vesicles, and absence of crusts rules out non-bullous impetigo s the priority diagnosis.
Erythema Multiforme: Erythema Multiforme (E.M.) is an acute and self-limited skin condition considered a type IV hypersensitivity reaction. It is associated with certain infections, medications, and other triggers (Hafsi & Badri, 2019). It present with pink macules with purple central papules. E.M. is categorized into E.M. minor and major. E.M. minor is characterized by a localized eruption of the skin with minimal or no mucosal involvement (Hafsi & Badri, 2019). The papules evolve into iris lesions that appear within 72-hours and begin on the extremities. The lesions remain fixed for at least 7 days and then start to heal. E.M. major manifests with localized eruptions that involve one or more mucous membranes (Hafsi & Badri, 2019). E.M. is a differential diagnosis based on the presence of red spots in the patient. However, the history of the spread of lesions makes E.M. an unlikely diagnosis.
Dermatitis herpetiformis: Dermatitis herpetiformis manifest with clustered excoriations, erythematous, urticarial plaques, and papules with vesicles (Antiga & Caproni, 2015). The dermatitis herpetiformis lesions are typically located on the extensor surfaces of the elbows, knees, buttocks, and trunk (Antiga & Caproni, 2015). It is extremely pruritic, and the vesicles are get excoriated to erosions. (Antiga & Caproni, 2015) This is a differential diagnosis based on positive findings of pruritic erythematous papular and vesicular lesions on the trunk. Pertinent negative findings include clustered excoriations and the presence of lesions on the scalp, face, and upper extremities. Besides, the presence of fever, malaise, and loss of appetite rules out dermatitis herpetiformis as a primary diagnosis.
Antiga, E., & Caproni, M. (2015). The diagnosis and treatment of dermatitis herpetiformis. Clinical, cosmetic and investigational dermatology, 8, 257–265. https://doi.org/10.2147/CCID.S69127
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th Ed.). St. Louis, MO: Elsevier Mosby.
Gershon, A. A., Breuer, J., Cohen, J. I., Cohrs, R. J., Gershon, M. D., Gilden, D., Grose, C., Hambleton, S., Kennedy, P. G., Oxman, M. N., Seward, J. F., & Yamanishi, K. (2015). Varicella-zoster virus infection. Nature reviews. Disease primers, 1, 15016. https://doi.org/10.1038/nrdp.2015.16
Hafsi, W., & Badri, T. (2019). Erythema Multiforme. In StatPearls [Internet]. StatPearls Publishing.
Hartman-Adams, H., Banvard, C., & Juckett, G. (2014). Impetigo: diagnosis and treatment. American family physician, 90(4), 229-235.
Kennedy, P., & Gershon, A. A. (2018). Clinical Features of Varicella-Zoster Virus Infection. Viruses, 10(11), 609. https://doi.org/10.3390/v10110609
The Lab Assignment
Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
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