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SOAP NOTE: DERMATOLOGY

Coursework Instructions:
NURS 6023 (12978.202610)Assignment3.3 SOAP Note: Dermatology Assignment 3.3 SOAP Note: Dermatology Use the following patient scenario to complete the SOAP note. Use the SOAP note template provided. Complete all sections of the SOAP Note pertinent to this visit. For VS > Temp: 98.9, HR 98, RR 22, BP 84/676, Pulse Ox on RA 99%, Height 41 inches, Weight 42 lbs, Pain level 3/10 Patient Scenario Gus Smith is a 5-year-old male who presents to your primary care clinic where you work as an APRN. Gus’s mother is concerned about a rash on his face. The rash began with small red bumps five days ago. Today, the rash has spread. This morning, the rash is around his mouth and lower nose area. She has noticed some yellow drainage. She has tried OTC antibiotic ointment and cleaning with Dial soap. However, the rash continues to worsen. Gus’ mother comments some other kids at school may have had the same rash. The mother reports that Gus is eating well and playing as usual. T 98.9, BP 84/76, HR 98, RR 22, HT 41”, WT 42 lbs When you Inspect the area, this is what you see: Impetigo If you copy and paste references from the course into your assignment, be sure to confirm APA formatting before submitting. SOAP Note Template guide.docxDownload SOAP Note Template guide.docx SOAP Note Impetigo Tips and Pointers.docxDownload SOAP Note Impetigo Tips and Pointers.docx Primary Diagnosis and Differential Diagnosis See the Goolby textbook - Chapter 4 regarding the primary and differential diagnoses. See the attached template to help you format the primary and differential diagnosis rationales. The differential diagnosis template is NOT required for the assessment. Instead, use this to help your learning process and improve your grade. Differential Diagnosis Example - Sore Throat.docxDownload Differential Diagnosis Example - Sore Throat.docx Differential Diagnosis Template.docxDownload Differential Diagnosis Template.docx Guide to understanding the rash differential diagnosis process. Inflammatory Dermatoses (Rashes).pdfDownload Inflammatory Dermatoses (Rashes).pdf SOAP Note Grading Rubric.2025 Criteria Ratings Points CC and HPI Meets or Exceeds Expectations CC identified and documented in appropriate format. HPI is addressing all components of OLDCARTS 10 pts Review of Systems Meets or Exceeds Expectations Appropriate problem-focused ROS, addressing specific symptoms, pertinent to the chief complaint, and includes subjective information only 8.1 to 10 pts Past medical, surgical, family, and social histories Meets or Exceeds Expectations Past medical, surgical, family, and social histories thoroughly reviewed and documented 10 pts Objective Data Meets or Exceeds Expectations Documented appropriately, addressing specific symptoms, pertinent to the chief complaint, includes only objective information. 8.1 to 10 pts Diagnostic measures are utilized and supported with current evidence-based literature. Meets or Exceeds Expectations Diagnostic measures are utilized and supported with current evidence-based literature. 10 pts Primary diagnosis Meets or Exceeds Expectations Primary diagnosis is correctly identified and appropriate rationales (from subjective and objective information) is identified utilizing evidence-based references with in-text citations included. 10pts. Differential diagnoses Meets or Exceeds Expectations At least 2 differential diagnoses were identified and excluded based on clinical decision-making information supported by evidenced-based literature with in-text citations included. 10 pts Pharmacological agents Meets or Exceeds Expectations Pharmacological agents are prescribed appropriately when indicated with correct dose, route, frequency, and duration of therapy 10 pts Patient education, specific patient considerations, and follow-up plan is identified Meets or Exceeds Expectations Patient education is addressed. Specific patient considerations are included in the education given, and follow-up plan is identified 10 pts Formatting: minimum of 5 current sources (within past 5 years) included in APA format, includes in-text citations in APA format Meets or Exceeds Expectations Five references are included on the reference page; articles are appropriate and current. References are in the correct APA format. In-text citations are included in APA format. 10 pts
Coursework Sample Content Preview:
NURS 6023-Advanced Assessment and Diagnostic Evaluation STUDENT NAME: __________________________________ Date: __________________________________________________________________ SOAP Note SUBJECTIVE Chief Complaint Red rashes on the face that began to appear five days ago, according to the patient’s mother. History of Present Illness The patient: A 5-year-old child suffering from red rashes that keep growing every day. Beginning of the Illness: The rashes appeared five days ago, and they appear as small red swellings or bumps. Now these bumps have spread around the mouth. They are also seen around the lower nose. According to the patient’s mother, these bumps have begun to produce yellow liquid today. Previous Treatment: The mother tried using OTC antibiotic ointment and soap, but this treatment did not improve the situation. According to the mother’s understanding, other children who study at the patient’s school may have this problem as well. Symptoms: The patient experiences slight itching with a pain level of 3/10. The patient is behaving normally as he has eaten enough and plays with children without any problem. There is no report of fever or chills, or any other changes in behaviour. Review of Systems (Problem-focused) General No report of fever; feeling of tiredness and experience of weight loss. Skin Skin is normal, other body areas are clear, with only rashes on his face with mild pruritus. No exposure to insect bites. Head The patient does not experience headaches, dizziness, or itching. Eyes There is no redness of the eyes, no drainage in the eyes, and no swelling in the eyes. Ears There is no drainage from the ears; no pain in the ears; no swelling in the ears. Nose No nose bleeds, mild and clear rhinorrhea, occasional sneezing. Mouth/Throat There are no lesions in the mouth. Also, the patient does not have a sore throat. No drooling Cardiovascular No sign of palpitation, no chest pain, no shortness of breathing Respiratory No sign of coughing, no wheezing, no cold or flu Abdomen The patient does not feel nausea and vomiting, no abdominal pain, no diarrhoea. GU No painful urination, no urgency in urination, no rashes Lymphatic No report of swollen glands, no tenderness in the neck, no recent illness MSK No pain in joints, no muscle pain, no immobility Neurology No report of dizziness, no sign of unconsciousness, no head injury Psychiatric No mood swings, no disturbance in sleep duration, a little concern about rashes Past Medical History No report of chronic illness; the patient has always been a healthy child with no hospitalisation. He has been immunised regularly. When he was an infant, he experienced a mild attack of eczema, but this problem was resolved easily. Past Surgical History The patient has not undergone any surgery in the past. No record of medical procedures, no record of hospitalisation Allergies The patient does not report signs of drug allergies. No report of food allergies, no indication of environmental allergies Medications When he had eczema, he was treated with Triamcinolone 0.1% cream, but now it is not in use, as the eczema is over. For the treatment of the present condition, the patient’s mother used an OTC antibiotic ointment on the child’s affected areas for three days. The patient has not used any other antibiotic. Family History . No family history of skin diseases. No family history of immune disorder. No family history of antibiotic-resistant microbial infection Social History The patient lives with his parents at home. Attends preschool. May have contact with other children who have rashes. OBJECTIVE (Problem-focused) Vital signs T: 98.9°F, BP: 84/76, HR: 98, RR: 22, HT: 41”, WT: 42 lbs, SpO2: 99% RA, Pain: 3/10. Physical Exam General Survey The patient appeared fit and healthy. The skin is soft and moist. No signs of distress level. Skin Rashes around the perioral and nares. Yellow liquid drainage. No other lesions anywhere Head Normal scalp size with no lesions. Normal hair growth. Normal shape of the head. Eyes Clear conjunctiva. No swelling in the periorbital area. Clear vision Ears Complete tympanic membrane. No lesions on the external ear. Hearing is good...
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