SOAP NOTE TEMPLATE (Episodic/Problem Visit)

Student Name: Date: Course:

Patient Demographics:
Age: 6 years

Gender: Male

Ethnicity: Caucasian

Chief Complaint: “My child has a rash on his face.”

History of Present illness: The patient's mother reports that her child developed a red, itchy
rash on his face about 3 days ago. She noticed small blisters that burst and formed honey-colored
crusts. The rash has since spread to the neck and hands. The child complains of itching but no
pain or fever.

Past Childhood Illnesses: No history of measles, mumps, rubella, varicella, scarlet fever,
rheumatic fever, or polio. The child has had asthma since age 3.

Past Medical History (PMH):

- Asthma diagnosis at age 3.

- Immunizations up to date, including Flu, Prevnar 13, and TdaP (last updated: 08/2022).

- Recent dental checkup (results: normal) and vision screening (results: normal).

Family Medical History (FMH):

Mother has a history of childhood asthma. No other relevant genetic risk history.

Personal History/Social History:

The patient is in school, lives with both parents, and has one sibling. The family lives in a
suburban area. The child enjoys playing outdoors and is not exposed to secondhand smoke or
illicit drugs. No alcohol use in the household.

Current Medications/OTCs/Supplements:

- Albuterol inhaler (use as needed for asthma symptoms)

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.
Review of Systems:

General: No fever
Skin: Itchy, red rash with honey-colored crusts

HEENT: No eye discharge, no ear pain

Respiratory: No cough or wheezing

Cardiovascular: No chest pain or palpitations

Gastrointestinal: No abdominal pain or diarrhea

Genitourinary: No urinary symptoms

Neurologic: No seizures or headaches

Screening Tool: ONE screening tool is required and it should be scored (e.g. PHQ-2 Depression
Scale, CRAFFT, etc.)—if screening is positive list as a diagnosis with a plan.

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.
Physical Exam:

Vital Signs:

- Blood Pressure: N/A

- Pulse: 80 bpm

- Respiratory Rate: 20 breaths/min

- Temperature: 98.6°F

- Pain: None

- Height: 4'2"

- Weight: 45 lbs

- BMI: 16.1

General: Alert and oriented, no distress

Skin: Erythematous, crusted lesions on face, neck, and hands

HEENT: Normal conjunctiva, tympanic membranes intact

Lungs: Clear to auscultation

Heart: Regular rate and rhythm

Abdomen: Soft, non-tender

Genitourinary: Normal external genitalia

Extremities: No clubbing, cyanosis, or edema

Neurological: Alert, no focal deficits

Pertinent Labs/Diagnostic Testing: No additional labs or diagnostics are indicated at this time.

Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential

diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required
below the table.

Differential Diagnoses Pathophysiolo Pertinent Positives Pertinent Negatives

gy
(include APA
citations)
1. Impetigo (ICD-10: Impetigo is a - No fever - Honey-colored
L01.0) bacterial skin crusted lesions
- Pruritus (itching) infection caused
- No systemic symptoms by
Staphylococcus
aureus or
Streptococcus
pyogenes. It
typically occurs
when the skin is
compromised,
allowing
bacteria to enter
and cause
infection
(Elmas et al.,
2021).
2. Contact Dermatitis Contact - Absence of vesicular - Possible exposure to
(ruled out) dermatitis is an lesions irritants/allergens
- Erythematous skin lesions inflammatory
- No fever skin reaction
triggered by
exposure to
irritants or
allergens. It
presents with
erythema,
itching, and
 skin lesions
(Schnopp et al.,
2011).
3. Scabies (ruled out) Scabies is - No burrows - Intense itching
- Possible burrows in the caused by observed
skin Sarcoptes
- Absence of vesicular scabiei mites,
lesions which burrow
into the skin,
leading to
intense itching
and
characteristic
burrows
(Salavastru et
al., 2017).
4. Herpes Simplex Virus HSV infection - No vesicular lesions - Vesicular lesions
(HSV) Infection (ruled causes vesicular observed
out) lesions that can
- Possible fever be painful,
- No systemic symptoms often
accompanied by
fever (McGuire,
et al., 2023).
5.

In a narrative format explain how you arrived at your final diagnosis or working diagnoses based
on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This
should be written using examples of how the history/clinical presentation led to the final
diagnosis or working diagnosis (APA citations to your references must be included – use
resources with Evidence Based Guidelines)

Diagnostic Reasoning:

Based on the patient's history, clinical presentation, and physical examination findings, the most
likely diagnosis is Impetigo, given the characteristic honey-colored crusts and pruritus.

Assessment/Plan:
Include a brief summary of the visit here

(APA citations required in your plan)

List diagnoses applicable to your patient encounter. Diagnosis #1 is your primary/working
diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the
ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be
followed by a plan of care that is evidenced based.

Diagnosis #1 ICD-10: L01.0 (Impetigo)

a. Plan:
 Prescribe topical antibiotic ointment (Mupirocin) to be applied three times daily for 7-10
days.

 Educate the patient's parents on proper hand hygiene to prevent further spread.

 Advise the parents to avoid scratching the lesions to minimize the risk of complications
and secondary bacterial infections.

Diagnosis #2 ICD-10: J45.901 (Asthma, unspecified, uncomplicated)

a. Plan:
 Review asthma management with the patient's parents.

 Ensure that the child's albuterol inhaler is readily available and demonstrate proper
inhaler technique.

 Discuss asthma triggers and the importance of avoiding them.

 Recommend an asthma action plan for the family to follow.

Diagnosis #3 ICD-10: Z23 (Encounter for immunization)

a. Plan:
 Discuss the upcoming influenza vaccine for the patient in preparation for the flu season.

 Provide information about the importance of annual flu vaccination to reduce the risk of
influenza and its complications.

Health Maintenance:

- Influenza vaccine discussion for the upcoming season.

- Review asthma management and ensure proper inhaler technique.

RTC: (Document disposition)

The patient should follow up in 7-10 days to assess the progress of Impetigo treatment and
ensure there are no complications or worsening symptoms.

References
Elmas, Ö. F., Akdeniz, N., Atasoy, M., & Karadag, A. S. (2020). Contact dermatitis: A great
imitator. Clinics in Dermatology, 38(2), 176-192.
McGuire, E., Li, A., Collin, S. M., Decraene, V., Cook, M., Padfield, S., ... & Brown, C. S.
(2023). Time to negative throat culture following initiation of antibiotics for pharyngeal
group A Streptococcus: a systematic review and meta-analysis up to October 2021 to
inform public health control measures. Eurosurveillance, 28(15), 2200573.
Salavastru, C. M., Chosidow, O., Boffa, M. J., Janier, M., & Tiplica, G. S. (2017). European
guideline for the management of scabies. Journal of the European Academy of
Dermatology and Venereology, 31(8), 1248-1253.

FACULTY ONLY
Grade __________