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Christine Dominguez

SOAP Note # 1

ID
09/10/2015, S.D. 49 year old Caucasian female; marital status, religion, advanced directives,
insurance, employment/occupation unknown.
CC
Rash with severe itch for the past 4 days
HPI
Patient developed a rash 4 days ago, appearing following a weekend of raking and burning brush
in her yard. Rash covers her arms, legs and chest. Her rash is raised, red, burning, and itchy.
Patient has not been able to identify anything that relieves the symptoms, and states that it is
worse at night. It is aggravated by n/a and possesses no other temporal factors. She states the
rash and pruritis are severe. She has treated the rash with calamine lotion, which has offered her
no relief of symptoms. Cant sleep due to itching
Onset: Past weeken
Location: arms, legs, chest
Duration: since ast weekend
Character: itchy burning
Ag:Working in yard
RF: calamine no help
Temp: night
Severity: keeps awake
PMH UNREMAKABLE FOR FOOD, SURGERIES,ETC)
Patient states she is in her usual state of health, other than the rash. Unknown surgeries,
hospitalizations, illnesses, or immunizations. Patient is presently on no medications, and has no
food, medicine or environmental allergies, although states she has a vague recollection of being
exposed to poison ivy as a child. Unknown blood transfusions, emotional status or psychiatric
history.
PERSONAL HISTORY
Patient has lived in Cityville all of her, life, and not had any recent travel. Marital status,
economic resources and occupation not assessed at this visit. She has her own home, and enjoys
working in her yard. No safety or abuse issues appreciated.
HEALTH HABITS

Christine Dominguez

SOAP Note # 1

Pt denies tobacco use, no illicit drugs, consumes 1-2 alcoholic drinks per week. She is active in
her yard, enjoys cooking and reading. She recalls raking and burning leaves this past weekend in
her yard. No Pets, No travel
HEALTH MAINTENANCE
Patient states she is up to date with health screening exams. Detailed review not completed at
this focused exam No information given
FAMILY HISTORY
Patient denies family history of dermatitis, rash or environmental allergies. No info given
REVIEW OF SYSTEMS
GENERAL
Patient denies fever, chills, night sweats, but states her sleep is interrupted due to intense pruritis.
feels well except for rash
DIET
Denies changes in appetite, new additions of vitamins or supplements. 24 hour diet recall not
assessed.
No info given
SKIN, HAIR, NAILS
Patient complaints of erythematous, raised rash to bilateral upper and lower extremities, as well
as on the upper thoracic chest. Patient complains of intense pruritis, unrelieved with topical
calamine. No hair or nail changes noted, though patient states she has trimmed her nails to
minimize scratching. (See HPI when more advance assess)
HEAD AND NECK
Not pertinent
EYES
No rash or exudate noted near the eyes.
EARS
Not pertinent (No info given}
NOSE
Patient states she has not experienced increased lacrimation or nasal stuffiness.
THROAT AND MOUTH
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Christine Dominguez

SOAP Note # 1

Patient states no complaints of sore throat, mouth pain, swelling of mucosa


GASTROINTESTINAL
No pertinent
LYMPH
Patient states she has not experienced any enlargement or tenderness of lymph tissue of head and
neck or axilla.
ENDOCRINE
Not pertinent
FEMALE
Not pertinent
BREASTS
Not pertinent
CHEST AND LUNGS
Patient denies cough, dyspnea, night sweats.
CARDIOVASCULAR
Patient denies chest pain, palpations or edema
HEMATOLOGY
Not pertinent
GENITOURINARY
Not pertinent
MUSCULOSKELETAL
Patient denies joint inflammation or pain

NEUROLOGIC
Not pertinent
MENTAL STATUS
Patient states she has had more difficulty concentrating, as well as increased irritability that she
relates to pruritis and sleep deprivation. {Poor sleep due to pruritic rash}
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Christine Dominguez

SOAP Note # 1

Physical Examination
VS
BP: 126/76, HR:81, Hgt: 56,wgt: 135#, BMI: 21.8
Temp:not given
RR: not given
GENERAL APPEARANCE
49 year old Caucasian female, with no gait or posture abnormalities noted.(unknown)
MENTAL STATUS
Patient is alert and oriented, (slightly restless unknown)
SKIN
Patient presents with an extensive reddened(erythematous), elevated, wheal rash to bilateral
upper extremities, as well as on the upper thoracic chest. A vesicular(papulovesicular) rash is
noted to the bilateral lower extremities and patellar regions, with areas of excoriation. No
evidence of exudate, or odor. Localized redness and inflammation noted. Patient complains of
intense itching, that has been unrelieved with topical calamine. (Can draw pictures)
Erythematous, papilvesicular rash to forearms, legs, chest in diffuse, linear, clustered pattern,
(does it have purulent discharge?) can add measurements. Appears to be scratched, round,
circular etc, with excoriated central areas, (is it anterior, posterior chest?)
HEAD
Not assessed
NECK
Not assessed
EYES
Pupils equal and reactive to light, no redness of sclerae or conjunctivae noted
EARS
Not assessed
NOSE
Nasal mucosa and turbinates pale pink, without swelling or tenderness, no nasal discharge noted.
MOUTH AND THROAT
4

Christine Dominguez

SOAP Note # 1

Lips, gums, tongue, tonsils, uvula and mucosa pink without lesions. No swelling, erythema or
exudate noted.
CHEST/LUNGS
Respirations regular, lungs clear to auscultation on this limited exam
Heart and lung on every exam
BREASTS
Not assessed
HEART
Not assessed
(Heart each time)
BLOOD VESSELS
Not pertinent

ABDOMEN
Not assessed
Because she drinkers
FEMALE GENITALIA
Not assessed
RECTUM
Not assessed
MUSCULOSKELETAL
No swelling or erythema or external warmth of joints noted
NEUROLOGIC
Not assessed
CRANIAL NERVES
Not pertinent
Diagnosis:
Poison ivy rash (Contact dermatitis 2 to poison ivy)
5

Christine Dominguez

SOAP Note # 1

DIFFERENTIALS
Contact dermatitis
Poison sumac
Poison oak
Environmental
atopic dermatitis
scabies
stress
PLAN: include pharmacologyRx written in plan as you would on a prescription pad or if
sent electronically; patient education and health promotion
Prednisone 20mg tabs, 2 tablets, qam x 5 days, #10, no refills
Benadryl 25-50mg, po, q 4-6 hours prn pruritis/insomnia
Zyrtec during day
?abx secondary to itching (Keflex)
Reviewed medication administration, adverse reactions, signs and symptoms of secondary
infection. Patient to return to clinic if symptoms worsen or do not improve. Will schedule a
follow up appointment in 1 week. Teach re: steroids, antihistamines, cool compresses, oatmeal
baths, cont. calamine,