Soap Note NUR 7070: Advanced Practice Nursing III Practicum (802)

Chief Complaint: “I’m worried about my daughter’s skin.”

Patient: Y.O.

Age: 2 years old

Sex: Female

DOB: 5/2/22

 Subjective

History of Present Illness: Y.O is an African American 2-year-old female who is here for an itchy rash on arms and knees. She was born via vaginal delivery at 38 weeks without any complications. At birth, she weighed 3.29 kg (7 pounds 4 ounces). Her APGAR was 9 at 1 min and 9 at 5 min. The patient is accompanied by her mother for today’s visit. Y.O’s mother states that she has noticed Y.O’s skin getting worse. She states that Y.O. had cradle cap as a baby ,but that went away. She states that Y.O. had dry skin behind her knees when she was younger that she placed lotion on and it cleared up.

However, the rash on Y.O’s behind the knees and arms has not gotten better with the lotion that she has placed on it. Her mother states that she has been using Johnson& Johnson’s baby lotion on her skin. Y.O’s mother denies changing soap or laundry detergent. She states she has been using the same soap and detergent since Y.O. was an infant. She denies Y.O. being exposed to any weeds, grass, or animals recently. Y.O’s mother states that she is unaware that Y.O has any environmental allergies.

Allergies: NKA, including NKDA and no allergic to latex

Medications: Currently not taking medications

PMH: No PMH

Past surgical history: NKH

Immunizations: Up to date

Family History: Mother: NMH

Family: eczema as a child

Social History: No smokers in the house. Mother and father raise Y.O. YO’s mother watches Y.O majority of the time and Y.O’s father works as a housekeeper in the hospital.

Fall Prevention in the Hospital Setting by Including Patients in the Cause

Nutrition: Formula for 1 year, now regular diet. Y.O. eats a healthy balanced diet filled with proteins and veggies. She has had no difficulties eating or drinking.

Elimination: Y.O. is still in diapers. Y.O’s mother wishes to start potty training soon.

Sleep: Y.O sleeps throughout the night without any issues.

Vision: There are no concerns for vision today.

Hearing: There are no concerns for hearing today.

Development & Behavior: There are no concerns for her development or behavior.

Safety: Y.O’s mother places Y.O in a five point harness car seat for transportation. Domestic violence is not a concern. Home has been child-proofed with all chemicals placed in high-locked cabinets. Medication is out of reach and locked. No firearms in the house.

Review of Systems

 General/Constitutional: Denies fatigue, Denies fevers or chills

HEENT: Denies ear pain, Denies eye problems, Denies hearing loss, Denies vision abnormalities, Denies sore throat, denies swelling of face or throat, Denies discharge from eyes, ears or throat.

Respiratory: Denies cough, wheezing, denies shortness of breath

Cardiovascular: Denies chest pain, palpitations, or edema in extremities

Integumentary: + rash on arms and behind knees, + pruritis

Gastrointestinal: Denies anorexia, denies abdominal pain, nausea, & diarrhea

Musculoskeletal: Denies pain or decreased range of motion

Neurological: Denies dizziness, denies headaches

Mental: + uncomfortable

Objective

 

Physical Examination

 

Vitals:

Temp: 98 F

BP: 94/58

HR: 110

RR: 20

 

Measurements:

Head circumference: 18 3/4in (48cm) (75%)

Ht: 33 ½ in (85 cm)(50%)

Wt: 28.7 lbs (13 kg)(75%)

BMI: 18 (85% overweight)

 

General: In no apparent distress, well-groomed and is appropriately dressed. Answers questions appropriately for age.

Skin: appropriate for ethnicity, dry cracked skin of darker color than surrounding area found with lichenification on antecubital fossa and popliteal area of both arms and legs. No hair or nail abnormalities

HEENT:

Head: normocephalic and symmetric. Face is symmetric.

Ears: Hearing test completed. Responds to questions and repeats words correctly >50% of the time. No abnormalities found to left and right auricles, non-tender to palpation bilaterally. No abnormalities found with left auditory canal.

Eyes: TMs gray and intact with expected light reflection.

Nose: Nasal mucosa pink and moist. Turbinates patent with no discharge present.

Throat: No swelling or palpable masses on neck. Oral Mucosa are pink and moist. Oropharynx is pink and moist. Tonsils fit within tonsillar fossa.

HEENT Tina Jones Shadow Health Transcript

Cardiovascular: S1 S2 heard, no extra heart sounds, regular rhythm.

Respiratory: Lung sounds clear to auscultation, no adventitious sounds heard in all fields. Chest rise and fall is symmetrical and patient appears to be in no respiratory distress.

Gastrointestinal: Normoactive bowel sounds

Musculoskeletal: not examined

Neurological: not examined

Assessment

Differential Diagnoses

 

 

Contact Dermatitis (L23.9)

 Contact dermatitis is a skin condition caused by a hypersensitivity reaction to substances such as plants, poison ivy, laundry detergent, soap, jewelry, or latex (Burns et al., 2020b). It is characterized by a rash localized to one area with sharp borders, redness, and sometimes vesicles (Burns et al., 2020b).

Y.O.’s mother has stated that there have been no recent changes in soap or laundry detergent and denies Y.O. being exposed to plants or animals. She also denies that Y.O. has a history of any known allergies. Additionally, Y.O.’s rash is not localized to one side. Based on this information, it is unlikely that Y.O. has contact dermatitis.

 Seborrheic dermatitis (L21.9)

Seborrheic dermatitis is a chronic inflammatory condition that occurs in areas with a high density of sebaceous glands, such as the scalp, face, and chest (Burns et al., 2020d). It is typically characterized by greasy yellow scales and reddened skin (Burns et al., 2020d).

Y.O.’s rash is characterized by dry, cracked skin with lichenification and is located behind the knees and on the arms, which are atypical sites and do not match the characteristics of seborrheic dermatitis (Burns et al., 2020). Additionally, seborrheic dermatitis is often not pruritic (Burns et al., 2020d). Therefore, I do not believe Y.O. has seborrheic dermatitis.

 Scabies (B86)

Scabies is a contagious skin infestation caused by the mite Sarcoptes scabei (Burns et al., 2020c). The parasite burrows into the epidermis, causing an intense, pimple-like rash (Burns et al., 2020c). The itching is often worse at night (Burns et al., 2020c). The rash is characterized as a vesiculopustular rash found in the armpits, wrists, and elbows (Burns et al., 2020c).

Y.O’s mother states that Y.O. sleeps well at night and does not complain of intense itching. The rash found on Y.O’s elbows and knees is not vesiculopapular. In addition, there is no mention that other family members or close contacts have similar symptoms. Therefore, I do not believe Y.O. has scabies.

Working Diagnosis

 Atopic Dermatitis (L20.9)

Atopic dermatitis is characterized by chronic, inflamed, and pruritic lesions that are dry and popular with circumscribed scaly patches (Burns et al., 2020a). It often involves flexor surfaces such as the antecubital and popliteal fossa (Burns et al., 2020a). It is commonly associated with a family history of a similar skin condition (Burns et al., 2020a).

 

Y.O.’s mother describes that Y.O. has a history of dry skin behind the knees and arms, which responded to lotion in the past. She now has a persistent rash on her arms and behind her knees that has not improved with the use of Johnson & Johnson’s baby lotion. This suggests the chronic and relapsing nature of atopic dermatitis (Burns et al., 2020a). Y.O.’s father has a history of eczema (atopic dermatitis), which increases the likelihood of Y.O. having atopic dermatitis, because there is a genetic predisposition (Burns et al., 2020a). On physical examination, Y.O. has pruritic dry, cracked skin of a darker color than the surrounding area with lichenification. The rash is found in the antecubital and popliteal areas, which are common signs of atopic dermatitis (Burns et al., 2020a). Therefore, I believe that Y.O. has atopic dermatitis.

 Plan

 Hydrocortisone cream 1% Apply 2 FTU (0.01g of hydrocortisone) to elbow creases and behind knees BID for 14 days.

Low-potency topical steroids are considered first-line treatment when managing atopic dermatitis in pediatrics (Young et al., 2021).

2. Encourage the mother to bathe daily using lukewarm water and apply an emollient or moisturizer immediately after such as Eucerin or Aquaphor at least twice daily

To prevent skin dehydration while bathing, it’s best to use a hypoallergenic soap and water at a temperature of 27-30°C (Kulthanan et al., 2021). Limit your time in the water to 5-10 minutes. After gently drying the skin, apply moisturizer or emollient to slightly damp skin (Kulthanan et al., 2021).

3. Educate the mother that she can administer OTC Children’s Zyrtec or Benadryl if pruritis is intense. Educate that Benadryl should be given at bedtime, because it can make child drowsy.

Antihistamines are widely used to treat acute flares of pruritus (Kulthanan et al., 2021). Sedating antihistamines may be helpful in reducing itching and promoting sleep during disease flares (Kulthanan et al., 2021).

4. Advise the mother to use soaps and detergents free of dye and fragrance to prevent irritating skin

Moisturizers for patients with AD should not contain any fragrance or preservatives, because fragrances have been shown to irritate skin and make atopic dermatitis worse (Kulthanan et al., 2021).

5. Dress the child in soft, breathable fabrics, like cotton

Breathable fabrics such as cotton, wick away moisture that can worsen atopic dermatitis condition (Kulthanan et al., 2021).

6. Follow up within 2 weeks if there is no improvement with steroid cream.

References

Burns, C. E., Dunn, A. M., & Blosser, C. G. (2020a). Atopic dermatitis. In Burns’ Pediatric Primary care (7th ed., pp.544-548). Elsevier.

Burns, C. E., Dunn, A. M., & Blosser, C. G. (2020b). Contact Dermatitis. In Burns’ Pediatric Primary care (7th ed., pp.597-598). Elsevier.

Burns, C. E., Dunn, A. M., & Blosser, C. G. (2020c). Scabies. In Burns’ Pediatric Primary care (7th ed., pp.592-593). Elsevier.

Burns, C. E., Dunn, A. M., & Blosser, C. G. (2020d). Seborrheic Dermatitis. In Burns’ Pediatric Primary care (7th ed., pp.599). Elsevier.

Young, T. K., Glick, A. F., Yin, H. S., Kolla, A. M., Velazquez, J. J., Nicholson, J., & Oza, V. S. (2021). Management of pediatric atopic dermatitis by primary care providers: A systematic review. Academic Pediatrics, 21(8), 1318–1327. https://doi.org/10.1016/j.acap.2021.07.008

Kulthanan, K., Tuchinda, P., Nitiyarom, R., Chunharas, A., Chantaphakul, H., Aunhachoke, K., Chularojanamontri, L., Rajatanavin, N., Jirapongsananuruk, O., Vichyanond, P., Chatchatee, P., Sangsupawanich, P., Wananukul, S., Singalavanija, S., Trakanwittayarak, S., Rerkpattanapipat, T., Thongngarm, T., Wisuthsarewong, W., Limpongsanurak, W., … Noppakun, N. (2021). Clinical practice guidelines for the diagnosis and management of atopic dermatitis. Asian Pacific Journal of Allergy and Immunology, 39(3), 145–155. https://doi.org/10.12932/AP-010221-1050

The SOAP note should be completed on a pediatric patient with a chronic or psychosocial condition you have seen in the clinical setting of this practicum course.

Soap note on 13 Year old male w/ hx asthma accompanied by father complaining of cough w/ phlegm for 3 days. He uses albuterol 90mcg per inhalation 2 puffs as needed every 4-6 H. Has been using inhaler more frequently.

T: 98.5F

HR: 106

Spo2: 98%

Ht: 68 in

Wt: 164 pounds

Lungs clear to auscultation

PFT: mild restrictive pattern disease

FVC: 77%

FEV1: 85%

FEV1/FVC: 109%

Assessment: cough variant asthma

Plan:

prednisone 20 mg BID for 5 days

singulair 10 mg PO daily

Flovent 2 puffs BID (110mcg per inhalation)