Soap Note on Patient with Eczema

Soap Note on Eczema Student’s Name Institutional Affiliation

Soap Note on Eczema

Soap Note on Patient with Eczema

Student’s Name: Date of Assignment:
Patient’s Initials: Date of encounter:
Sex: Male Age/DOB/Place of Birth: 3 years
Historian: Mother.CC: “My child has brownish patches of dry, thickened, cracked, scaly skin on his upper chest and the inside of his elbows and knees.”
Child profile:Child can name of the things that she is familiar with, and she is able to show affections for other children and make friend without prompting. Child can also turn book pages one at a time and he can also kick a ball. He is helped to do most of his daily activities by his parents or their nanny and he is potty trained. The child is also able to show a wide range of emotions, dress and undress herself, and gets upset with major changes ion routine. Child walks easily and is kept out of reach of medications at home and equipments that can cause harm to him such as electronic equipments.
HPI:A 3 years old Caucasian boy is brought to the office by his mother who reports that the child has brownish patches of dry, thickened, cracked, scaly skin on his upper chest and the inside of his elbows and knees. She also says that the patches of skin are itchy and the child keeps scratching them and she has recently noted that the skin is becoming sensitive, swollen from scratching. She adds that the itchiness worsens at night disrupting the sleep of the child. Mother reports that the symptoms started three days ago and she tried Oatmeal bath, cold compresses and emollient on the child but the symptoms have persisted. Mother says that child has not been bitten by an insect recently and she does not use irritating soaps and oil on the child. She also denies chronic ailment and current medication on the child.
PMH:Hospitalization: None. Medical intolerance: None.

Immunizations: Influenza vaccine administered last year in August and there is no record of missed vaccination.

Allergies: Child has no allergies. Chronic disease: None.

Major traumas: None.

Surgeries: None.

Family History: Mother has asthma and father have no history of chronic ailment.
Social History: Patient lives with his biological parents and their nanny. His parents also own a puppy and they do not own a gun. Patient attends pre-school in the neighborhood but is currently staying at home. He is potty trained and is not allowed near house equipments that have the potential of harming him. Patient sits in his child seat while traveling and he enjoys playing with his peers and his toys. Child does not take alcohol, tobacco and illegal drugs. Mother also denies drug abuse and cigarettes ad says that she takes alcohol once in a while with her husband and the alcohol is kept out or reach of the child. Mother also adds that the family lives in a safeestate.
General: Mother denies high body temperatures, night sweats, chills, increased or decreased energy levels, abrupt changes inweight and fatigue. Respiratory: Mother denies wheezes, shortness of breath, difficult respirations, and rapid and shallow breathing.
Skin: Mother reports brownish patches of dry,thickened, cracked and scaly skin on the Cardiovascular: Mother denies palpitations,chest edema, fast heart rate, irregular heart rate
child’s upper chest and the inside of his elbows and knees. She also reports that some patcheslook sensitive and swollen from scratching. and pain, stiffness and tenderness in the chest.
Developmental Problems: Mother denies any cognitive, social, emotional, communication,and physical developmental problems. Soap Note on Patient with Eczema Musculoskeletal: Mother denies muscle pains, difficulties moving back, shoulders, arms andlegs.
Neurologic: Mother denies loss of consciousness, syncope, episodes of passingout, weakness and headaches. Psychiatric: Mother reports disrupted sleep because of itchy sensation and scratching atnight and denies unusual behaviors.
Height: 3’ 2” Temp: 98.5 BP: 97/61
Weight: 32 lbsBMI: 15.6 kg/m2 Pulse: 89 Resp: 26
Weight-for-age percentile:54% Height-for-age percentile:65% BMI-for-age percentile: 36%
General Appearance and child-parent interaction. Patient looks well built and nourished and is insore acute distress. He plays with his toys as I talk to his mother and keep turning to check if his mother is still there when he gets bored with a game.
Skin: The skin on the upper chest and the inside of the elbows and knees has dry, thickened, cracked and scaly skin patches that are brownish in color. Patient scratches the dry patches of skin then continues playing with his toys. Some patches also look sensitive and swollen fromscratching.
Neurological: Gait is normal, balance is stable as patient runs easily falling often, speech is clearand tone is good as patient’s words are understandable.
Cardiovascular: Pulse is normal, heart rate and rhythm are normal, capillaries refill in 2 secondsand murmurs, rubs and extra sounds are not heard on auscultation.
Respiratory: Respirations are not difficult and they are regular. Lungs are clear to auscultationbilaterally and chest wall is symmetric.
Musculoskeletal: Patient walks, runs and kicks a ball with ease. He raises his hands, moves his
shoulders and bends with no difficulties.
Psychiatric: No behavioral problems are observed with the child and he plays normally with histoys only coming to his mother once in a while to show her what he has constructed.
Pediatric/Adolescent Assessment Tools: Vital: The BMI, weight, and height for age percentile are within the normal range. Other vital signs are also within the normal range for the age of the child. Teeth development is within the normal range for the age of the child. Eating assessment: The common foods that the child takes includes green vegetables, cereals, milk and fruits. Living status: Child lives in a safe estate. Musculoskeletal development: Child kicks a ball and runs easily. He also has a stable balance and erect posture. Child met the normal developmentalmarkers for 3 years old boy.
Lab tests:No lab test was ordered and diagnosis was clinical.
Differential Diagnosis:C84 – Mycosis fungoides: Condition that affects the skin causing lesions, rash, tumors and itchy skin. Patient presented with some of these symptoms but did not present with scales which are a common feature of Mycosis fungoides. The condition is also common in persons with advanced age and patient is a child hence ruling out the diagnosis.

L400 – Psoriasis: A skin condition that is characterized by multiplication of cells up to 10 times faster than normal hence resulting to the buildup of bumpy red patches on the skin which are covered with white scales (Di Meglio & Nestle, 2017 Soap Note on Patient with Eczema ). Patient reported dry, thickened, cracked and scaly skin patches but did not report scales and well-circumscribed patches that are red in color hence making the diagnosis less likely.

B86 – Scabies: contagious skin condition caused by infestation of tiny mites called sarcoptes scabie and characterized by itchy skin with a rash. Patient reported itchy skin that worsens at

night but there were no burrows that were seen and no similar symptoms were reported in close

contacts of the patient and this ruled out the diagnosis.Primary Diagnosis:

L20. 9 – Atopic dermatitis: Also known as eczema and characterized by itchy and discolored skin. It is common in children and occurs periodically. Its common symptoms are dry skin, itching that worsens at night, brownish to reddish patches of skin mainly in the hands, ankles, neck, upper chest, feet, eye lids, wrists, and the inside part of elbows and knees (Page, Weston & Loh, 2016). The condition also presents as small raised bumps which form crust when they are scratched, thickened, cracked and scaly skin and raw, sensitive and swollen skin upon scratching. Patient presented with most of these signs hence confirming Atopic dermatitis as the primary diagnosis.

Treatment Plan
Vaccines administered at this visit: None.Medication prescribed: Hydrocortisone topical 2.5% to be applies firmly to affected area q12hr (Sidbury & Kodama, 2018).

Patient Education: Mother advised to moisture the skin of the patient at least twice a day, apply bandages on the affected skin, bathe child with warm water with sprinkled baking soda and uncooked oatmeal and dress child with smooth texture clothes.

Laboratory tests ordered: None Diagnostic tests ordered: None.

None medical treatment: Recommended therapies such as wet dressing, light therapy, counseling an relaxation.

Follow up: Patient to make a follow up visit if symptoms persist after treatment and if patient

experience severe side effects of medication.

References for Soap Note on Patient with Eczema

Di Meglio, P., & Nestle, F. O. (2017). Immunopathogenesis of Psoriasis. In Clinical and Basic
Immunodermatology (pp. 373-395). Springer, Cham.Page, S. S., Weston, S., & Loh, R. (2016). Atopic dermatitis in children. Australian family physician, 45(5), 293.

Sidbury, R., & Kodama, S. (2018). Atopic dermatitis guidelines: Diagnosis, systemic therapy, and adjunctive care. Clinics in dermatology, 36(5), 648-652.

Growth chart for a 3 years old boy: Weight-for-age percentile: 54%, Height-for-age percentile: 65% and BMI-for-age percentile: 36%.