NURS 6541
Week 10 SOAP Note
Patient Initials: LB Age: 4-years-old Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): “dry, itchy patches to bend of arms and left wrist.”
History of Present Illness (HPI): This is
...
NURS 6541
Week 10 SOAP Note
Patient Initials: LB Age: 4-years-old Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): “dry, itchy patches to bend of arms and left wrist.”
History of Present Illness (HPI): This is a 4-year-old African American female patient
who presents with itchy patches to bilateral antecubital areas and to left wrist for two weeks with
no improvement. Mother states that the child has experienced these same patches several times
over the last two years but they were beginning to occur more often. Patient and patient’s mother
denies any pain, burning, or drainage at sites. Mother denies any changes in laundry detergent,
lotions, soaps, or medications with child. Mother states that the itching seems to worsen at night
and that she has not tried any treatment therapies at site. Mother denies exposure to individuals
with similar symptoms.
Medications: No routine or as needed medications.
Allergies: No known allergies.
Past Medical History (PMH): No history of recent or past hospital administrations. No medical
history.
Review of Systems:
General: Child appears to be well-nourished, healthy, and in no acute distress. Child
appears well groomed and neatly dressed. Denies fever, chills, weight loss, loss of
appetite, or fatigue.
HEENT: no visual disturbances or changes, denies sensitivity to light, hearing
disturbances or ear pain, nasal congestion or discharge, sneezing, throat pain, difficulty
swallowing, or cough
References
Barry, M. (2018). Scabies. Retrieved from https://emedicine.medscape.com/article/1109204-
overview
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.)
(2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.
Feldman, S. R. (2018). Epidemiology, clinical manifestations, and diagnosis of psoriasis.
Retrieved from https://www.uptodate.com/contents/epidemiology-clinicalmanifestations-and-diagnosis-of-psoriasis
Fenstermacher, K. & Hudson, B. T. (2016). Practice guidelines for family nurse practitioners (4th
ed.). St. Louis, Missouri: Elsevier.
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