Question

I need a brief SOAP note for a pretend patient that has come to the ER with a skin rash.

S:

O:

A:

P:

Answer 1

Ans. N is a 23-year-old woman who comes to ER complaining of a skin rash.

Ms. N complains of frequent “breakouts” on her face for the last several years. She reports the use of many topical over-the-counter agents over the years. She complains of feeling greasy and the need to “squeeze pus” out of lesions on a regular basis.

- On examination, over the forehead, cheeks, and chin there are many erythematous papules, occasional pustules, and open and closed comedones. There is a predominance of larger nodules along the jaw line. Similar erythematous papules involve the upper back and chest. There is neither significant background erythema nor scaling in the scalp, eyebrows, or nasolabial folds.

- The patient is in good health and is not overweight. She is not taking any oral medications. She reports regular menstrual cycles and notes that the breakouts are worse around the time of her period. She does not report easy flushing or any increased hair growth on the face or chest. She has 1 healthy child.

- A management plan was discussed with the patient, including an appropriate skin care regimen, appropriate product selection, and use of systemic and topical medications. At follow-up in 3 months, the patient had significantly fewer active lesions with evidence of dyspigmentation associated with resolving lesions.

S:23- year old woman who complains of rash and breakouts for the last several years, seeks treatment now for regularly feeling greasy and the needing to “squeeze pus” out of lesions. Breakouts worsen around the time of her period. She does not report easy flushing, hair growth on the face or chest. She has used many topical over-the-counter agents over the years.

O: Skin:Erythematous papules, few pustules and open and closed comedones on the forehead, cheeks and chin. Large predominate nodules on the jaw line. Erythemayous papules on the chest and back.

Scalp/ eyebrows/ nasolabial folds: unremarkable, no significant background erythema, or scaling

A: Chronic acne vulgaris

Rosacea

Perioral dermatitis

P: Counseling and management plan was discussed on appropriate skin care regimen, product selection and use of systemic and topical medications.