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Pages:
2 pages/≈550 words
Sources:
3 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Other (Not Listed)
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
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Topic:

Soap Note: Pityriasis Rosea

Other (Not Listed) Instructions:

Students will be assigned a Common Primary Care Pediatric Acute Care Problem for which they will submit a comprehensive SOAP note by Sunday of week 4. This is a comprehensive H & P including all parts of a SOAP note, epidemiology of the problems, incidence and brief pathophysiology . Do not forget the growth charts, proper citations, APA format, at least 3 solid differentials, and at least 3 evidence-based references.
All late submissions are subject to a 5 point deduction/day.
Pityriasis Rosea
Hannah is a 16-year-old presenting to the school-based health center asking for treatment of a rash. Hannah notes that she has multiple red, raised oval-shaped scaly patches on her stomach and back. They are a little itchy and she has used over the counter hydrocortisone on them which does not seem to be helping. She is seeing several new patches every day for the past 3 days. Upon questioning she notes that last week she didn’t feel great and had a mild headache and felt tired. She took a COVID at home test which was negative. Hannah wants to know if she should be worried that her boyfriend will “catch whatever this is from me?”
Your diagnosis is pityriasis rosa. Follow the SOAP guidelines as noted in the template and be certain to cover all points as they relate to the patient and the diagnosis. Note the typical rash presentation and characteristics. What are your differential diagnoses and how did you rule them out? Note treatment and recommendations and expected effectiveness. Include age-appropriate anticipatory guidance.
I have attached the completed written soap note , need to do the soap note with the provided scenario which is a 16 year old with the rash listed on the scenario. For 16 year old you can use the family history of the soap note that I sent it for sample, make the growth chart of normal development of the child, you can use CDC growth chart and plug in the information. Please feel free to ask questions if need to. thanks

Other (Not Listed) Sample Content Preview:
SOAP NOTE
Subjective
Patient Initials or First Name: Hannah
DOB/Age: 16 Years old
CHIEF COMPLAINT (CC)/ Reason for Visit: “I am asking for treatment of a rash.” – Hannah, the patient.
MEDICAL HX (PMH): Hannah reports a negative test result for COVID-19 from a home test.
Hospitalizations: None
ED/Urgent Care Visits: None
Surgeries: None
Sleep: Hannah does not provide information to indicate that the disorder affects her sleep habits.
Medications: Hannah has tried over-the-counter hydrocortisone
Allergies: No information was provided
Family Medical History: None
Sexual History: Not provided
Social History: Hannah is in a relationship with an unnamed boyfriend, with the concern that she might pass the rash to her boyfriend being a major concern.
HEALTH CARE MAINTENANCE:
REVIEW OF SYSTEMS: (document who provides information) (Parent or Guardian denies or Reports)
General: Hannah reports presenting with multiple red, raised, oval-shaped scaly patches on her stomach and back, which are itchy. She reports seeing new patches every day for the past 3 days. She reports experiencing a mild headache and feeling tired last week
Objective
PHYSICAL EXAM:
APPEARANCE: Upon examination, Hannah had rashes that presented as multiple oval-shaped, red, raised scaly patches on the stomach and back.
Skin: A skin examination of Hannah revealed rashes on her skin. The rashes were oval or circular, with a well-defined border as well as a clear center. The majority of the patches were pink or red. In terms of appearance, the rashes were scaly and exhibited a silvery appearance. The rashes were distributed from the trunk to her limbs, with their sizes ranging from a few millimeters to several centimeters in diameter. The skin was also tender to the touch.
Assessment (Chosen Diagnosis)
Pityriasis rosea 2023 ICD-10-CM Diagnosis Code L42
Differential Diagnoses
Lichen planus: The disease was considered an alternative diagnosis. Its distinguishing characteristics include the presence of papules measuring 1-10 mm on the wrist, shins, scalp, mouth, lumbar regions, and glans penis (Eisman & Sinclair, 2015). The disease was eliminated as some of the rashes were several centimeters larger.
Nummular eczema: The disease was considered as an alternative diagnosis: It is characterized by small vesicles and papules that are 4-5 cm in diameter size. The lesions are round and coin-shaped and are often on the back of one’s hand and shins (Villalon-Gomez, 2018). The diagnosis was ruled out because the patient has lesions that were significantly smaller in size and the presentation of the lesions ...
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