Running Note: SOAP NOTE: PEDICULOSIS 1
SOAP Note: Pediculosis
Identifying Data and Chief Complain
A 14yearold female and Puerto Rican, comes to the clinic with her mother for an acute
visit. The mother explains that her daughter is healthy, but this morning the mother found louse
in her daughter’s scalp. “My daughter is complaining for the last two days of intense itching in
her scalp that is severe at night. When she was combing this morning, she found white nits
attached to the hair. I inspected her head minutely and I found approximately 10 live louse in her
scalp. My younger 5yearold daughter has had lice infestation many times during the last year
and early this year. I reported this health problem to the school direction, but they have never
taken action about it”. She explain that her youngest daughter has again lice infestation since
last week, when mother took all the precautions to prevent contagious to other family members.
Patient has a private medical insurance, MCS. Her father is the primary cardholder.
Subjective Symptoms
1. “intense itching in the scalp that is severe at night”
2. “white nits attached to the hair and approximately 10 live louse in the scalp”.
Subjective Data
Past medical history (PMH): Mother informs that the patient had a healthy childhood, only had
varicella and some common colds, last in November 2015. Mother did not have complications
during gestation and patient’s vaginal delivery. Mother nursed the patient until one year old.
Patient’s menarche: May 2015. LMP: February 7, 2016. Patient exercises three times a week in
tennis classes at school. Immunizations are up to date, including Influenza, HPV and Hepatitis B
(January 21, 2016).
, SOAP NOTE: PEDICULOSIS 2
Family history: Mother is a 32-year-old healthy woman with no history of chronic diseases.
Father is a healthy 35-year-old man with no history of chronic diseases. Patient has a 5-year-old
healthy sister. Her grandfather from the father’s side is a 57-year-old man with obesity and
hypertension. Her grandmother from the father’s side is healthy 53-year-old woman. Her
grandfather from the mother’s side died in a car accident six years ago at 51-year-old. Her
grandmother from the mother’s side is a 56-year-old woman with hypothyroidism.
Past social history (PSH): Patient lives with parents and her 5-year-old sister. The father is a
US Army soldier and the mother is a teacher, but does not work outside home as this moment.
Immunization: Vaccines are up to date, including Influenza (January 21, 2016).
Allergies: No known allergies (NKA).
Surgical history: No surgeries history.
Medication history: No medication history.
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Mother denies patient’s weight changes during the last year.
Skin: Patient denies skin lesions, acne, dry skin, no nodules, no new moles, no dry hair and no
eczema. Patient reports intense itching in her scalp that is severe at night and that she has white
nits and louse in hair shift. Patient reports pain by scratching the scalp.
HEENT: Patient denies hear difficulty or tinnitus, no congestion, no dental or swallowing
problems and no vision problems and no use of eyeglasses.
Respiratory: Patient denies rhinitis, dyspnea, hemoptysis, cough or secretions.
Cardiovascular: Patient denies tachycardia, bradycardia, palpitations, orthopnea or chest pain.
Gastrointestinal: Patient denies appetite changes or abdominal pain. Reports normal bowel
movements and no changes in elimination frequency or consistency, no indigestion or heartburn.
SOAP Note: Pediculosis
Identifying Data and Chief Complain
A 14yearold female and Puerto Rican, comes to the clinic with her mother for an acute
visit. The mother explains that her daughter is healthy, but this morning the mother found louse
in her daughter’s scalp. “My daughter is complaining for the last two days of intense itching in
her scalp that is severe at night. When she was combing this morning, she found white nits
attached to the hair. I inspected her head minutely and I found approximately 10 live louse in her
scalp. My younger 5yearold daughter has had lice infestation many times during the last year
and early this year. I reported this health problem to the school direction, but they have never
taken action about it”. She explain that her youngest daughter has again lice infestation since
last week, when mother took all the precautions to prevent contagious to other family members.
Patient has a private medical insurance, MCS. Her father is the primary cardholder.
Subjective Symptoms
1. “intense itching in the scalp that is severe at night”
2. “white nits attached to the hair and approximately 10 live louse in the scalp”.
Subjective Data
Past medical history (PMH): Mother informs that the patient had a healthy childhood, only had
varicella and some common colds, last in November 2015. Mother did not have complications
during gestation and patient’s vaginal delivery. Mother nursed the patient until one year old.
Patient’s menarche: May 2015. LMP: February 7, 2016. Patient exercises three times a week in
tennis classes at school. Immunizations are up to date, including Influenza, HPV and Hepatitis B
(January 21, 2016).
, SOAP NOTE: PEDICULOSIS 2
Family history: Mother is a 32-year-old healthy woman with no history of chronic diseases.
Father is a healthy 35-year-old man with no history of chronic diseases. Patient has a 5-year-old
healthy sister. Her grandfather from the father’s side is a 57-year-old man with obesity and
hypertension. Her grandmother from the father’s side is healthy 53-year-old woman. Her
grandfather from the mother’s side died in a car accident six years ago at 51-year-old. Her
grandmother from the mother’s side is a 56-year-old woman with hypothyroidism.
Past social history (PSH): Patient lives with parents and her 5-year-old sister. The father is a
US Army soldier and the mother is a teacher, but does not work outside home as this moment.
Immunization: Vaccines are up to date, including Influenza (January 21, 2016).
Allergies: No known allergies (NKA).
Surgical history: No surgeries history.
Medication history: No medication history.
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Mother denies patient’s weight changes during the last year.
Skin: Patient denies skin lesions, acne, dry skin, no nodules, no new moles, no dry hair and no
eczema. Patient reports intense itching in her scalp that is severe at night and that she has white
nits and louse in hair shift. Patient reports pain by scratching the scalp.
HEENT: Patient denies hear difficulty or tinnitus, no congestion, no dental or swallowing
problems and no vision problems and no use of eyeglasses.
Respiratory: Patient denies rhinitis, dyspnea, hemoptysis, cough or secretions.
Cardiovascular: Patient denies tachycardia, bradycardia, palpitations, orthopnea or chest pain.
Gastrointestinal: Patient denies appetite changes or abdominal pain. Reports normal bowel
movements and no changes in elimination frequency or consistency, no indigestion or heartburn.
