Chicken Pox SOAP

SOAP NOTE 1
Chicken Pox SOAP NOTE
Name
Institutional Affiliation
Date
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SOAP NOTE 2
STUDENT NAME: DATE OF ASSIGNMENT:

Patient Initials: GH Date of Encounter: 11/19/19
Sex: Female Age/DOB/Place of Birth: 10 Years
SUBJECTIVE
Historian: Mother
CC: “She has been having an itchy rash, high fever and red blisters that are fluid-filled that
turn to scabs.”
Child Profile: GH is a 10-year-old Hispanic girl who has achieved all her developmental
milestones. Has no abnormality or childhood disorder. Is in school and performs well. Spends
most of her time in school and has a nanny hence no day care. She is able to perform basic
chores and sleeps at 9pm and wakes up at 6am. Goes to school for five days a week and
spends the weekends with parents. Has no defect or allergies.
HPI: GH is ten years old. She is brought to the clinic by her mother due to blisters that are
filed with fluid and eventually turns to scabs. Mother of the patient also reports that the patient
has a rash which is itchy especially in the chest, back and face. She states that the rash has
spread in most parts of the body. Reports to have it in the eye lids and inside of the mouth.
Other related symptoms mentioned by the patient’s mother include a fever as the last
temperature reading was 103F last night. She reports that GH has significantly lost her
appetite, she feels fatigues, her lymph nodes are swollen and reports of a two-day-old sore
throat. She rates her discomfort a 6 out of 10 in a scale of 0-10. Reports that the blisters are
very painful. Reports of headaches but denies vomit, nausea and diarrhea. Denies having used
any medications to treat the symptoms.
Medications: None used.
PMH:
Allergies: None reported
SOAP NOTE 3
Medication Intolerances: Denies.
Chronic Illnesses/Major traumas: Denies.
Hospitalizations/Surgeries: Denies
Immunizations: Reports that all immunizations are updated.
Family History: The mother is 31 years old and the father is 36 years old, both alive with no
major chronic illnesses. Grandparents from both sides live in Michigan and are all alive with
no chronic illnesses reported. Patient has no siblings.
Social History: Patient is in elementary school and attends school from Monday to Friday.
Spends time with parents while at home. Parents do not use any drugs such as tobacco and
marijuana. They also d not use alcohol.
Review of Systems
General Cardiovascular
Reports of fever, fatigue, headache and Denies orthopnea, chest pain, PND and
decreased energy levels. Denies changes in palpitations.
weight.
SOAP NOTE 4
Skin Respiratory
Reports of blisters that are filed with fluid and Denies coughing, hemoptysis, wheezing and
eventually turns to scabs. Mother of the breathing difficulties. Denies coryza and TP
patient also reports that the patient has a rash or pneumonia history.
which is itchy especially in the chest, back
and face. She states that the rash has spread in
most parts of the body. Reports to have it in
the eye lids and inside of the mouth. Denies
delayed healings, moles and discolorations.
Eyes Gastrointestinal
Denies loss of vision, eye discharge, pain or Reports of loss of appetite. Denies vomit,
blurring. nausea and diarrhea. Denies abdominal pains,
constipation, hemorrhoids and black tarry
stools.
Ears Genitourinary/Gynecological
Denies loss of hearing, discharge, ear pain or Non-contributory.
ringing
Nose/Mouth/Throat Musculoskeletal
Denies runny nose, dysphagia or nose bleeds. Denies swollen, painful and tender joints,
Reports of sore throat. Denies dental illnesses. denies back pain and movement difficulties.
Breast Neurological
Non-contributory. Denies syncope, black out spells, weaknesses,
seizures and paresthesia.
Heme/Lymph/Endo Psychiatric
Reports of swollen lymph nodes. Denies Pt’s mother denies lack of concentration,
increased hunger and thirst. Denies anxiety, depression and insomnia.
intolerances for cold or heat.
SOAP NOTE 5
OBJECTIVE
Weight 45 lbs Temp 101F BP 118/78
Height 48 Inches Pulse 78 Resp 18
OBJECTIVE
General
Patient is well developed, well dressed and nourished in mild distress. Not exciting but is able
to keep an eye contact.
Skin
Positive for skin rash with red blisters that are filled with fuel. Blisters seem to pop and leak.
Skin rash noted on the back, chest and face. Free from bleeding and discolorations.
HEENT
Head: Free from injuries and bruises, hair is rough and distributed evenly. Normocephalic and
atraumatic.
Eyes: PERRLA. Pupils of equal size and reactive to light. Free form sclera and conjunctivae
injection. Blisters and rash noted in the eye lids
Ears: Have bilateral TMs. Patent canals that have positive light reflexes. Free from discharge,
erythema and inflammations.
Nose: Nasal mucosa is pink, free from lesions, bruises, discharge and inflammations. Oral
mucosa is pink and moist. Red blisters noted in the mouth.
Throat: Supple neck with trachea at the midline. Free from cervical lymphadenopathy and has
a full range of motion.
Cardiovascular
Pressure and pulses are regular with no palpitations heard. Free from gallops, extra sounds,
clicks and murmurs.
Respiratory
Breaths are easy and unlabored. Free from wheezes and coughs. Chest wall is symmetrical and
lungs bilateral and clear to auscultation.
Gastrointestinal
Abdomen is flat, non-distended and soft. Free from guarding, hepatosplenomegaly and hernia.
Bowel sounds are heard in all quadrants.
SOAP NOTE 6
Breast
Deferred
Genitourinary
Deferred.
Musculoskeletal
In all extremities, range of motion is full.
Neurological
Pt’s speech is clear with a good tone. Posture is erect, steady gait and erect posture.
Psychiatric
Keeps a good eye contact, appropriately responds to questions and is aware of the ongoing.
Well-dressed and cooperative.
Lab Tests
ELISA- Pending results
Pediatric/Adolescent Assessment Tools

No tools use in this case.
ASSESSMENT
1) Chicken Pox B01.9- This is because of the itchy skin rah and red blisters that the patient
presents with. Normally, with this illness, the rash may spread to the face, chest and back of
the patient. The patient may also have the red blisters that are fluid-filled turning to scabs in
the eye lids, inside the mouth and may extend to the genitals (Kumar, Kothari & Gupta, 2016).
A patient with chicken pox may also have a fever, loss of appetite and fatigue. This is an
SOAP NOTE 7
infectious disease that spreads from one person to another and due to these symptoms, the
illness is the primary diagnosis.
2) Measles B05.9- This is due to the skin rash and high fever presented by GH. With measles,
the patient may have a rash that spreads in most parts of the upper body. Rash may be made up
of large and flat blotches that flow to each other. The patient may have spots in the inner lining
on the cheek, sore throat as in this case, dry cough and runny nose. The fact that the patient is
not coughing makes it easy to exclude this illness as the primary diagnosis.
3) Pediatric Rubella P35.0- Reasons behind this differential is due to the skin rash and high
fever reported by the patient. This illness may be associated with runny nose and diarrhea.
Other symptoms include low fever which excludes it as a main diagnosis and periods of
feeling unwell.
PLAN
To reduce the fever, the patient will take Tylenol 25mg PO PID for a period of five days. The
patient will take Ibuprofen 250mg PO PID for five days to ensure that the headaches and sore
throat reduces (Khondaker, Amin, Setu & Roy, 2016). For itching, the patient will take
Cetirizine 5mg two times a day for five days. The patient is advised to stay indoors and not go
to school until all the blisters are dry and have formed scabs as this is a contagious illness.
ELISA test is ordered for further assessment. The patient is also advised to increase the fluid
intake. The patient is advised to take a colloidal oatmeal bath twice a day and avoid
overdressing or high temperature environments. This will help in reducing the rashes and the
blisters. After this bath, the patient will be required to apply calamine lotion to quicken the
healing process. The patient is to apply petroleum jelly on the body or any other anti-itching
lotion (Hasan & Khader, 2018). To avoid unwanted allergic reactions, the patient is to avoid
over the counter antibiotics as the illness is mild. To avoid skin infections caused by
scratching, the patient’s nails are to remain short. If the symptoms do not improve within
seven days of treatment or if the child has trouble breathing, the patient is to come back for a
follow-up. Referral will be done to a dermatologists for further evaluation.
SOAP NOTE 8
References
Hasan, T., & Khader, K. (2018). Significance of Adult Chicken Pox Infections in Saudi Arabia: A
Case Report. Significance, 4(1).
Khondaker, T., Amin, S. K., Setu, M., & Roy, K. (2016). Post Chickenpox Sequel in Children:
Three Distinct Presentation. Anwer Khan Modern Medical College Journal, 7(2), 45-52.
Kumar, M., Kothari, N., & Gupta, B. D. (2016). Autoimmune Haemolytic Anaemia in a Child
Due to Chickenpox. Indian Journal of Hematology and Blood Transfusion, 32(4), 522-
524.
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Chicken Pox SOAP

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SOAP NOTE 1

Chicken Pox SOAP NOTE

STUDENT NAME: DATE OF ASSIGNMENT:

Sex: Female Age/DOB/Place of Birth: 10 Years

Medications: None used.

Allergies: None reported

Medication Intolerances: Denies.

Chronic Illnesses/Major traumas: Denies.

Immunizations: Reports that all immunizations are updated.

Weight 45 lbs Temp 101F BP 118/78

Height 48 Inches Pulse 78 Resp 18

Pediatric/Adolescent Assessment Tools

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