WEEK 3 SOAP NOTE
A 17-year old male presents with a complaint of a red itchy rash over his torso and back x 1
week which is keeping him up at night. He denies sick exposures or recent visit to wooded
areas. Denies other complaints.
CC: Red itchy rash over torso and back x 1 week.
S: Subjective
HPI: 17-year old male presents with a complaint of a red itchy rash over his torso and back x 1
week which is keeping him up at night. He denies sick exposures or recent visit to wooded
areas. Denies other complaints at this time.
Onset: 1 week
Location: Torso and back
Duration: Intermittent and at night
Contributing factors: Denies sick exposures or recent visit to wooded areas.
Relieving factors: Rest
Treatments: None at this time
PMH: None provided, it will be assumed patient has no past medical history.
FH: Not provided
SH: Lives in home with family
Immunizations: Not provided, it will be assumed that patient is current with all immunizations
Allergies: Not provided, it will be assumed patient has NKDA
Current medications: None provided
ROS:
General Appearance: Reports intense itching to torso and back, appears tired from lack of sleep
due to not being able to rest at night. Patient is cooperative and pleasant, dressed appropriately
for his age.
Cardiac: Do you have any chest pain?
Respiratory: Do you have any shortness of breath or cough?
GI: Do you have any abdominal pain? Nausea/vomiting? Constipation?
Skin: Can you tell me about your rash? When did it first start? What did your rash initially look
like? What were you doing initially before the rash started? Have you recently changed any new
soaps, detergents, or lotions? Where on your body did the rash first appear? Why are you not
able to sleep at night? Have you seen any of your family or friends itching?
A 17-year old male presents with a complaint of a red itchy rash over his torso and back x 1
week which is keeping him up at night. He denies sick exposures or recent visit to wooded
areas. Denies other complaints.
CC: Red itchy rash over torso and back x 1 week.
S: Subjective
HPI: 17-year old male presents with a complaint of a red itchy rash over his torso and back x 1
week which is keeping him up at night. He denies sick exposures or recent visit to wooded
areas. Denies other complaints at this time.
Onset: 1 week
Location: Torso and back
Duration: Intermittent and at night
Contributing factors: Denies sick exposures or recent visit to wooded areas.
Relieving factors: Rest
Treatments: None at this time
PMH: None provided, it will be assumed patient has no past medical history.
FH: Not provided
SH: Lives in home with family
Immunizations: Not provided, it will be assumed that patient is current with all immunizations
Allergies: Not provided, it will be assumed patient has NKDA
Current medications: None provided
ROS:
General Appearance: Reports intense itching to torso and back, appears tired from lack of sleep
due to not being able to rest at night. Patient is cooperative and pleasant, dressed appropriately
for his age.
Cardiac: Do you have any chest pain?
Respiratory: Do you have any shortness of breath or cough?
GI: Do you have any abdominal pain? Nausea/vomiting? Constipation?
Skin: Can you tell me about your rash? When did it first start? What did your rash initially look
like? What were you doing initially before the rash started? Have you recently changed any new
soaps, detergents, or lotions? Where on your body did the rash first appear? Why are you not
able to sleep at night? Have you seen any of your family or friends itching?
