Discussion Topic: Soap Note: Scabies
Requirements
– The discussion must address the topic
– Rationale must be provided mainly in the differential diagnosis, and it must have at least 3 differential diagnosis.
– Use at least 600 words (no included 1st page or references in the 600 words)
– May use examples from your nursing practice
– Formatted and cited in current APA 7
– Use 3 academic sources, not older than 5 years. Not Websites are allowed.
– Plagiarism is NOT permitted
I have attached the SOAP note template, a SOAP note sample, and the rubric. Discussion Topic: Soap Note
Requirements
– The discussion must address the topic
– Rationale must be provided mainly in the differential diagnosis
– Use at least 600 words (no included 1st page or references in the 600 words)
– May use examples from your nursing practice
– Formatted and cited in current APA 7
– Use 3 academic sources, not older than 5 years. Not Websites are allowed.
– Plagiarism is NOT permitted
I have attached the SOAP note template, a SOAP note sample, and the rubric.
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
•
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.
Differential diagnosis (minimum 4)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• –
• –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
ChatGPT
SOAP Note #1 Main Diagnosis: Scabies
PATIENT INFORMATION
Name: John Doe
Age: 32
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: None known
Current Medications: None
PMH: No significant medical history
Immunizations: Up to date
Preventive Care: Last annual physical examination was 6 months ago
Surgical History: No previous surgeries
Family History: Non-contributory
Social History: Employed as a construction worker, lives alone
Sexual Orientation: Heterosexual
Nutrition History: No specific concerns reported
Subjective Data:
Chief Complaint: Itching and rash all over the body for the past week
Symptom analysis/HPI: The patient reports experiencing intense itching and the development of a rash all over his body, particularly in the areas between his fingers, on his wrists, and around his waistline. The itching is worse at night and has been disturbing his sleep. The patient denies any recent changes in soaps, detergents, or clothing. He states that a coworker was diagnosed with scabies last month.
Review of Systems (ROS):
CONSTITUTIONAL: No fever, chills, or weight loss reported.
NEUROLOGIC: No headaches, dizziness, or changes in sensation reported.
HEENT: No changes in vision, hearing, or nasal congestion reported.
RESPIRATORY: No cough, shortness of breath, or chest pain reported.
CARDIOVASCULAR: No chest pain, palpitations, or swelling reported.
GASTROINTESTINAL: No abdominal pain, nausea, vomiting, or changes in bowel movements reported.
GENITOURINARY: No urinary symptoms or changes in urinary habits reported.
MUSCULOSKELETAL: No joint pain, swelling, or stiffness reported.
SKIN: Itching and rash all over the body, especially between fingers, on wrists, and around waistline.
Objective Data:
VITAL SIGNS: Blood pressure: 120/80 mmHg, Pulse: 80 bpm, Temperature: 98.6°F, Respiratory rate: 16 breaths per minute
GENERAL APPEARANCE: Patient appears well-nourished and in no acute distress.
NEUROLOGIC: Alert and oriented to person, place, and time.
HEENT: Pupils equal, round, and reactive to light. No signs of head or facial trauma.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops.
RESPIRATORY: Clear breath sounds bilaterally, no signs of respiratory distress.
GASTROINTESTINAL: Abdomen soft and non-tender, no organomegaly or masses palpated.
MUSCULOSKELETAL: Full range of motion, no deformities or swelling noted.
INTEGUMENTARY: Diffuse erythematous papular rash present all over the body, particularly in the interdigital spaces, wrists, and waistline. Some excoriations noted.
ASSESSMENT:
During my encounter with the patient, John Doe, I observed and assessed his subjective and objective data. He presented with intense itching and a diffuse erythematous papular rash all over his body, consistent with the clinical presentation of scabies. The patient denies recent exposure to potential irritants, but reports a coworker diagnosed with scabies last month. The characteristic distribution of the rash, intense itching, and the history of close contact with an individual diagnosed with scabies strongly support the diagnosis.
Main Diagnosis:
Scabies (ICD-10: B86.0)
Differential diagnosis: exposure to potential irritants, contact dermatitis should still be considered as a differential diagnosis. Contact dermatitis is an inflammatory skin condition caused by direct contact with an irritant or an allergen. It typically presents with erythema, itching, and sometimes vesicles or oozing. However, in this case, the distribution of the rash, particularly between the fingers, on the wrists, and around the waistline, along with the intense itching that worsens at night, is more consistent with scabies rather than contact dermatitis.
Atopic dermatitis: Atopic dermatitis, also known as eczema, is a chronic inflammatory skin condition characterized by itching, erythema, and dry, scaly patches. While atopic dermatitis can present with generalized rash and itching, the specific distribution seen in scabies, especially between the fingers and on the wrists, is not typically observed in atopic dermatitis. Additionally, the sudden onset and intense itching reported by the patient are more suggestive of scabies.
Pediculosis: Pediculosis, commonly known as lice infestation, is another differential diagnosis to consider. Lice infestation can cause itching and the presence of small red bumps or sores on the skin. However, the distribution of the rash in scabies, particularly in the interdigital spaces, wrists, and waistline, is different from the typical distribution of lice infestation, which is often seen in the hair, scalp, or pubic area. Moreover, lice infestation does not typically cause itching that worsens at night.
PLAN:
Labs and Diagnostic Tests to be ordered:
Skin scraping: A skin scraping can be performed to identify the presence of Sarcoptes scabiei mites, their eggs, or fecal matter, which can confirm the diagnosis of scabies. The scraping is usually taken from the burrows or areas with active lesions.
Pharmacological Treatment:
Topical Permethrin: Permethrin is the treatment of choice for scabies. It is a synthetic pyrethroid that acts by paralyzing and killing the mites. The cream should be applied to the entire body from the neck down and left on for 8-14 hours before washing off. This treatment should be repeated after 1 week.
Topical Lindane: Lindane is an alternative treatment option, but it is associated with a higher risk of neurotoxicity and is not recommended as a first-line therapy. Lindane should be used with caution, especially in children, pregnant women, and individuals with seizure disorders.
Symptomatic Relief: Antihistamines such as diphenhydramine can provide symptomatic relief from the itching associated with scabies.
Non-Pharmacologic Treatment:
All personal clothing, bedding, and towels should be washed in hot water and dried on high heat to kill any mites.
Close contacts, including household members and sexual partners, should also be treated simultaneously, even if they are asymptomatic, to prevent reinfection.
Education:
The patient will be educated on the importance of completing the full course of treatment and avoiding close physical contact with others until the infestation is resolved.
The patient will be instructed on proper hygiene practices, such as regular handwashing and avoiding sharing personal items, to prevent the spread of scabies.
Follow-ups/Referrals:
The patient will be scheduled for a follow-up appointment in two weeks to monitor treatment response and assess for any signs of reinfection.
Referral to a dermatologist may be considered if there is no improvement or if complications arise.
References:
CDC. (2019). Scabies. Retrieved from https://www.cdc.gov/par
Contact dermatitis: Although the patient denies recent
