SOAP note
SOAP Note—Hair, Skin, Nails
Subjective: Mark W. comes to the clinic today with complaint of “I have an itchy red rash that I think is from Poison Oak.” Patient states that rash is on both legs from the knees down to feet; reports that it developed approx. 24 hours after a hiking trip last weekend. Denies pain. Denies nausea, vomiting, fever. Reports “itching, burning legs and feet.” Patient reports having had this reaction to Poison Oak twice before. No other allergies reported. Reports no changes to moles and no history of other skin conditions. Patient reports using calamine lotion x 2 days and OTC diphenhydramine 25 mg tablets po q 12* for symptom relief.
Objective: Patient is sitting upright on examination table with legs uncovered and shoes/socks off. VS 128/82, HR 86, RR 16, T 37.1*C. There is bilateral lower extremity erythematous rash with fluid-filled vesicles spread throughout. Area around sock-line at ankles appears more inflamed. Rash extends to tops of feet. Skin appears more erythematous in areas where hair is more densely distributed—legs and tops of feet. Ankles and soles of feet are clear. Face and arms are dark tan with freckles; there is a distinct line of demarcation at biceps and neck where skin has prior sun exposure.
Assessment: Based on symptoms, appearance, and history, this patient most likely has Poison Oak hypersensitivity reaction and allergy. He has Impaired Skin Integrity with a Risk for Infection.
Plan: I recommend that Mark cut his fingernails short and keep them clean, and to refrain from scratching rash and spreading it. Cool compresses and continued OTC itch relief. I recommend that he wear long pants, long-sleeved shirts and hiking boots to keep skin protected while hiking. Sunscreen is a must for outdoor activity. Monthly skin checks for changes in moles. Follow up with MD if rash begins to ooze pus, if spreads to genitals or face, or if patient has a fever higher than 38*C.
Subjective: Mark W. comes to the clinic today with complaint of “I have an itchy red rash that I think is from Poison Oak.” Patient states that rash is on both legs from the knees down to feet; reports that it developed approx. 24 hours after a hiking trip last weekend. Denies pain. Denies nausea, vomiting, fever. Reports “itching, burning legs and feet.” Patient reports having had this reaction to Poison Oak twice before. No other allergies reported. Reports no changes to moles and no history of other skin conditions. Patient reports using calamine lotion x 2 days and OTC diphenhydramine 25 mg tablets po q 12* for symptom relief.
Objective: Patient is sitting upright on examination table with legs uncovered and shoes/socks off. VS 128/82, HR 86, RR 16, T 37.1*C. There is bilateral lower extremity erythematous rash with fluid-filled vesicles spread throughout. Area around sock-line at ankles appears more inflamed. Rash extends to tops of feet. Skin appears more erythematous in areas where hair is more densely distributed—legs and tops of feet. Ankles and soles of feet are clear. Face and arms are dark tan with freckles; there is a distinct line of demarcation at biceps and neck where skin has prior sun exposure.
Assessment: Based on symptoms, appearance, and history, this patient most likely has Poison Oak hypersensitivity reaction and allergy. He has Impaired Skin Integrity with a Risk for Infection.
Plan: I recommend that Mark cut his fingernails short and keep them clean, and to refrain from scratching rash and spreading it. Cool compresses and continued OTC itch relief. I recommend that he wear long pants, long-sleeved shirts and hiking boots to keep skin protected while hiking. Sunscreen is a must for outdoor activity. Monthly skin checks for changes in moles. Follow up with MD if rash begins to ooze pus, if spreads to genitals or face, or if patient has a fever higher than 38*C.