Running head: SOAP NOTE 1

Atopic Dermatitis SOAP NOTE

Name

Institutional Affiliation

Date
SOAP NOTE 2

Student’s Name: Date:

Sex: Male Age: 7 Years old, 3/5/2015, Houston, Texas

SUBJECTIVE
Historian: Mother
CC: “He has been itching and has notable cracks behind the ears.”

Child Profile: Child is 7 years old and lives together with his parents and two siblings. In
elementary school and does not go to day care. He loves playing with friends and is above
average academically. He has achieved all developmental milestones for his age and has no
childhood disorder. He sleeps at around 8:30pm and wakes up at 6:30am especially during
weekdays. Has a nanny who helps him with basic chores and spends most of his weekends
bonding with parents. Has a good relationship with his siblings.
HPI: DK is a seven-year-old who comes to the clinic with the mother’s company. Reports of
itching and notable cracks behind the ears. The mother of the patient reports that symptoms
presented have been there for four days. Mother reports that the skin of the patient is dry and
scaly. Adds that there are cases of redness and rashes on the cheeks and arms. Patient’s mother
also reports that there are sores that are weepy when they are disturbed. Denies trauma,
headache, nausea and vomit. Patient’s mother denies any allergies or a related history. Denies
any active medications.

Medications: Denies using any medications.

PMH:

Allergies: Denies having any allergies.

Medication Intolerances: Denies having medication intolerances.

Chronic Illnesses/Major traumas: Denies trauma and any major traumas.

Hospitalizations/Surgeries: Denies having been hospitalized/ having surgeries.

Immunizations: All immunizations are updated.

Family History: Patient’s mother and father are 29 years and 32 years old respectively. Both
are alive and have no medical illnesses. Patient has two siblings, one younger and one older
sibling (5 years and 12 years respectively). The two siblings are healthy and alive.
SOAP NOTE 4

Grandparents from the two sides are alive and live in Michigan. All grandparents are healthy
and alive with no major illnesses.

Social History: Patient lives with his parents and siblings. Has a nanny and is in 6th grade and
loves playing with his friends. He spends most of his weekends with parents. Mother reports
that the patient eats healthy and loves eating snacks. Parents do not smoke, drink alcohol or
any drug abuse. Patient loves swimming too and is good academically.

Review of Systems

General Cardiovascular
Mother denies loss of weight or energy levels. Denies chest pain, palpitations and
Denies fever, chills and night sweats. Reports orthopnea.
to be a bit dull and uncomfortable.

Skin Respiratory
Reports of itching and notable cracks behind Denies coughing, breathing difficulties and
the ears. Patient’s mother reports that the skin wheezing. Denies having a history of TB or
of the patient is dry and scaly. Adds that there pneumonia.
are cases of redness and rashes on the cheeks
and arms. Patient’s mother also reports that
there are sores that are weepy when they are
disturbed. Denies trauma, headache, nausea
and vomit. Patient’s mother denies any
allergies or a related history. Denies having
SOAP NOTE 5

used any medication to treat the symptoms.

Eyes Gastrointestinal
Patient’s mother reports that the patient does Denies pain in the abdomen, stomach upsets,
not use corrective lenses. Denies vision vomit, nausea or constipation. Denies black
changes, blurring, pain or discharge. tarry stools and loss of appetite.

Ears Genitourinary/Gynecological
Denies hearing loss or changes. Denies ear Non-contributory.
pain, discharge or ringing.

Nose/Mouth/Throat Musculoskeletal
Denies nose bleeds or discharge. Denies sinus Denies having movement difficulties, back
complications, dental complications, and pain and joint complications such as swelling,
throat pain or voice hoarseness. tenderness and pain.

Breast Neurological
Non-contributory. Denies seizures, syncope, weakness, black
out spells and paresthesia.

Heme/Lymph/Endo Psychiatric
Patient’s mother denies having any Denies anxiety, insomnia, depression and
transfusion of blood. Denies intolerances of concentration deficits.
heat or cold. Also denies and increased
SOAP NOTE 6

hunger or thirst.

OBJECTIVE

Weight 41lbs Temp 98F BP 119/78

Height 49 Inches Pulse 78 Resp 17

OBJECTIVE

General
Pt. appears sick with notable skin rashes on the cheeks. In mild distress but is well developed
as per the age. Appears to scratch parts of his skin especially in the face.
Skin
Skin is dry and has weepy sores especially on the hands and around the neck, cheeks have
rashes and scales at the back of the ears. Skin erythema is noted. Major bruises are absent.
General skin pigmentation is brown free from masses and lumps.
HEENT
Head is atraumatic and normocephalic with no bruises or injuries noted. Hair is well
distributed. Eyes have pupils that are reactive to light and are of equal sizes. Erythema absent,
sclera is white and conjunctivae injection absent. Eyes are free from discharge. Ears are of
equal size with patent canals and bilateral TMs free from ear discharge. Erythema and
inflammation absent. Pink nasal mucosa free from erythema, lesions and inflammations. Pink
and moist oral mucosa moist free from lesions and bruises. Teeth are in good health. Neck is
supple with trachea positioned at the midline.
Cardiovascular
Pressure and pulses are healthy as per the patient’s age with absence of murmurs, clicks,
gallops and extra sounds.
SOAP NOTE 7

Respiratory
Symmetrical chest wall with easy and unlabored breaths. Lungs clear to percussion and
auscultation. No wheezes or coughs heard.

Gastrointestinal
Abdomen is flat, soft and non-tender. Guarding and hepatosplenomegaly are absent with
bowel sounds active in all the quadrants.

Breast
Deferred

Genitourinary
Deferred.

Musculoskeletal
Gait is steady with no movement difficulties. Range of motion is full upon movement.
Developmental milestones are achieved as per the patient’s age.

Neurological
Clear communication abilities with an intact sensation of touch. Speech is clear with a good
tone.
Psychiatric
Keeps a good eye contact and questions are answered appropriately. Patient is pleasant and is
able to concentrate with the ongoing.
In-house Lab Tests – document tests
Elevated serum immunoglobulin E (IgE) levels – Pending results.

Pediatric/Adolescent Assessment Tools

ASSESSMENT

1) Atopic Dermatitis ICD10- L20.9- This is the primary diagnosis in this case. Reasons
behind this is due to the scales and cracks behind the ears and itchiness felt by the patient.
Other symptoms include redness, weepy sores and rashes that may appear on the cheeks, arms
or legs (Gortel, 2018).

2) Flexural eczema ICD10- L20.82- This is due to the mentioned itchiness and dryness of the
skin. Other symptoms in this illness include redness, rashes and flakiness. However, symptoms
such as bumps, peeling off and fissures are associated with this illness and absent in this
patient hence the illness is ruled out as the primary diagnosis.

3) Infantile eczema ICD10- L20.83- This is due to the itchiness and skin dryness mentioned
by the patient. Other symptoms include rashes and weepy lesions similar to this case.
However, symptoms that help in ruling out this illness include bumps and skin thickening.
Plan
SOAP NOTE 9

The patient will take hydrocortisone 1% powder that will be in an ointment base and will
apply it two times daily to the lesions in the folds and in the cheeks for ten days. The patient
will also take levocetirizine 1.25mg which will be half a teaspoon two times daily for ten days
(Kilpatrick, Hutchinson & Bouchoucha, 2019).
Patient is advised to avoid soap and irritants that may worsen the symptoms. Patient should
ensure to observe hygiene and avoid environments that may worsen the symptoms. He should
also avoid scratching the skin as the sores may turn to wounds hence infection (Andy-Nweye
et al., 2019). If the symptoms do not improve by 50% in the next five days, the patient should
come back to the clinic for follow-up and further assessment. If by the end of the medication
period the patient will not have improved, referral will be done to a dermatologist.
SOAP NOTE 10

References

Andy-Nweye, A. B., Jois, S. K., Jungles, K. N., Tobin, M. C., & Mahdavinia, M. (2019). Mode
of delivery and duration of pregnancy is associated with allergy to milk and atopic
dermatitis in children. Journal of Allergy and Clinical Immunology, 143(2), AB144.

Gortel, K. (2018). An embarrassment of riches: An update on the symptomatic treatment of

Kilpatrick, M., Hutchinson, A., & Bouchoucha, S. L. (2019). Nurse's perceptions on infection
prevention and control in atopic dermatitis in children. Infection, disease & health.