Do A Soap Note With Tonsillitis
SOAP NOTE: SCABIES 1
SOAP Note: SCABIES 2
Miami Regional University
Age: 48 years old
Insurance: Private insurance.
Chief complaint: ” My skin itches a lot at night”
History of present illness (HPI): Patient is a Hispanic white male 48 year old who is coming to consultation today reporting that for a week he is having a lot of itching in the internal fold of elbows and legs that makes it difficult for him to sleep properly. He also says he lived for two months with his mother in a shelter. Patient denies a history of dermatitis or atopy and states that he is not using any OTC cream or lotion and the skin lesion has increased as well as itchy.
Past Medical History(PMH)
Last annual physical exam was made in January of current year.
Chronic Condition: Essential Hypertension Controlled with current treatment
Current Medication: Enalapril 20 mg 1 tab PO QD
Hospitalization: Patient denies hospitalizations or invasive procedures.
No history of mental illness or personality disorders.
No physical trauma or falls reported during the last twelve months.
Surgeries: Cholecystectomy 7 years ago
Exposure: Patient lived in a shelter for two months due to economic problems that were already solved. No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues.
Environmental exposure was negative to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time.
Immunizations: Immunizations up to date (Flu Vaccine: 01/23/2019)
Exercise: Patient refers frequently daily exercises.
Diet: Patient refers a “healthy diet” rich in whole grains, vegetables, fruits and proteins.
Social History: Patient is single, and lives with his mother in an apartment. The relationships between family members is good. Client denies using drugs, alcohol or cigarettes.
Educational level: Middle School.
Sexual Behavior: Patient is heterosexual and he reported one sex partner during the past year. Client said that he always uses condom. No risk behavior for STDs.
Allergies: NKDA, No Food/Seasonal Allergy
Family Medical History: Mother (75 y/o) Alive : HTN, Diabetes mellitus and Father: Unknown.
Review of systems:
Systemic: The systemic symptoms presented at this time is skin itchy. No chills, no neck rigidity. No weight loss.
Head: No headache. No sinus pain reported, no mass, no trauma.
Neck: No pain or stiffness reported in this area. No swollen glands in the neck.
Eyes: No redness, pruritus or secretion. Denies blurred vision, double vision or other conditions.
Oto-laryngeal: No change in hearing, ringing in ears, neither ear pain. Not presence of sinus/nasal congestion or bleeding gums.
Breasts: No symptoms such as pain, fulness sensation or discharge.
Cardiovascular: Denies chest pain, palpitations, discomfort neither occasional episodes of irregular rhythm.
Pulmonary: Denies chest congestion, wheezing, coughing, frequent infections or shortness of breath.
Gastrointestinal: Normal appetite. No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation.
Genitourinary: No pain, hematuria or changes in urinary habits. No cloudy urine or bad smell. No penile discharge.
Endocrine: No symptoms. No polyuria, no polyphagia.
Hematologic: Denies easy bruising, loss of hair, heat/cold intolerance, change in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.
Musculoskeletal: Denies limited range of mobility, joint pain or limited ROM. Denies difficulty walking or trouble reaching above head.
Neurological: Denies migraine, balance problems, seizures or fainting lightheadedness, tremors or balance problems. Denies muscle weakness, numbness or tingling.
Psychological: Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.
Skin: The patient denies presence of white or brown spots, ulcer, ecchymosis, new nevus. During the interview he reports a lot of itchy during night for the las weeks localized in internal fold of elbows and legs.
BP-sitting L: 120/80 mmHg
BP cuff size: Regular
Pulse Rate-Sitting: 78 bpm
Pulse Rhythm: Regular
Respiration Rate: 15 per min
Temp-Tympanic: 98.1 F0
Height 70 in
Body Mass Index: 29.1 Kg/m2
Body Surface Area: 1.97 m2
Oxygen Saturation: 98 %
Pain Scale/Rate: 0/10
General appearance: Patient alert and oriented. Speech fluently. Currently; he no reflects discomfort in his face and posture. He is hydrated without increase of temperature.
Head: Normocephalic / no trauma. Scalp pink and dry. No tenderness noted over frontal or maxillary sinuses.
Neck: No visible mass and skin with normal coloration. No palpable masses or tenderness, trachea is midline, thyroid without nodules, no JVD, no lymph nodes.
Eyes: Extraocular movement in both eyes are symmetric. PERRLA, sclera is white, conjunctiva pink, no noted discharge. Normal visual acuity.
Ears: External auditory canal and meatus are normal. No swollen or reddened. Bilateral tympanic membranes were intact and pearly gray with light reflex. No erythematous, scarred or hemorrhage. No pus or serous exudate. No hearing loss.
Nose: No external deformities of the nose. Nasal mucosa moist and pink with clear drainage, septum midline. Nasal turbinate no erythematous, no swollen. No sinus tenderness.
Oral Cavity: Oral mucosa moist and pink. Gums with normal appearance without swollen, bleeding or hypertrophy. Teeth, the dentition are complete and good hygiene.
Pharynx: Moist and pink with tonsillar enlargement without lesions, plaques or exudate. No petechias, no strawberry tongue.
Lymph Nodes: No adenomegaly on observation on palpation in any of the ganglion’s chains.
Chest: Thorax symmetric, follow up the breading movement.
Lungs: Respirations are regular, equal, and unlabored with symmetrical chest expansion. Lung sounds clear to all lung fields. No wheezing, stridor, crackles, or rhonchi noted. No increased tactile fremitus noted.
Cardiovascular: Regular rate and rhythm, heart sounds of S1 and S2, no extra heart sounds, murmurs or bruits noted. PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard. No gallops, murmurs, or opening snaps.
All pulses 4+ palpable and equal. No clubbing, cyanosis or edema noted. Bilateral carotid arteries without bruits. Capillary refill test was normal.
Inspection: Symmetric, no distended no visible masses. The skin is normal, no scars
Auscultation: Bowel sound active in all 4 quadrants. No bruits.
Palpation: Abdomen soft, no mass, non-tender or guarding. No hepatomegaly or splenomegaly.
Genitalia: Patient refused genital exam at this time.
Rectal: Patient refused rectal exam at this time.
Musculoskeletal: Normal gait, no limited range of mobility (joints). Normal inspection, palpation, muscle strength. Fingers, feet and toes are normal.
Neurological: Level of consciousness was normal. Patient oriented in person, time and space. Speech clear and fluent. Normal sensory/motor exam. Deep tendon reflexes symmetrical and equal bilaterally. Proprioception was normal. Balance, gain and stance were normal. No peripheral neuropathy was noted.
Psychiatric: Patient is euthymic, with normal level of anxiety and depression. The affect was normal.
Skin: Clean, warm and dry without sores or bruises. No suspicious nevi, no bruises or ecchymoses. On observation is noted the presence of burrows and vesicles in internal fold of elbows, knee and inner part of both thighs. Also, it was observed excoriated papules.
Hair: Normal distribution according to the gender. No hair loss in the lower extremities was observed.
Nails: Pink with normal appearance. No clubbing of the finger nails. No onychomycosis.
Primary Diagnosis: B86 Scabies
It is an infestation of the skin by the mite Sarcoptes scabiei that results in an intensely pruritic eruption with a characteristic distribution pattern. The incidence of scabies undergoes cyclical fluctuations on a worldwide basis, although all parts of the globe are not necessarily in the same phase of the cycle at the same time. Transmission of scabies is usually from person to person by direct contact. In adults, areas most likely to yield mites are between the fingers, sides of hands, wrists, elbows, axillae, groin, breasts, and feet. Scabies usually presents with severe itching, often worse at night, and nondescript erythematous papules.
Atopic Dermatitis: is a chronic inflammatory skin condition that appears to involve a genetic defect in the proteins supporting the epidermal barrier. Exacerbating factors in atopic dermatitis that disrupt an abnormal epidermal barrier include excessive bathing, low humidity environments, emotional stress, xerosis or dry skin, overheating of skin, and exposure to solvents and detergents.
Impetigo: is a contagious superficial bacterial infection observed most frequently in children. It may be classified as primary impetigo direct bacterial invasion of previously normal skin or secondary impetigo infection at sites of minor skin trauma such as abrasions, minor trauma, and insect bites, or underlying conditions such as eczema. Variants of impetigo include non-bullous impetigo, bullous impetigo, and ecthyma.
Folliculitis: Multiple follicular-based erythematous papules or pustules on chest and back.
No burrows seen on physical exam.
Essential Hypertension (Controlled) I10
Permethrin 5% cream, massage thoroughly into the skin from the neck to the soles of the feet x 1 time, cream should be removed by washing after 8 to 14 hours. Apply a second time after two weeks.
Hydroxyzine tab 25 mg BID for 5 days.
Patient was instructed regarding general measures:
1. Treatment for those who were sexual and household contacts within the preceding 1 month is recommended at the same time that the patient is treated to prevent re-infestation.
2. Immediately following any treatment, all bedding and clothing should be washed in water that is 140°F or higher (≥60°C) and dried the day after the first treatment to decrease the chance of re-infestation.
3. Clothing or objects that cannot be washed should be placed in a sealed bag for a week.
No Test ordered/No needed to this diagnosis
Follow-up in 3 weeks. Also, the patient was instrumented to return if the symptoms get worse.
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