Isabelle Whitehead
10/5/22
295 Lab
Soap Note #1
Subjective:
Patient is a 22 year old identifying as male, who’s pronouns are he / him / his. Pt presents to clinic
with chief complaint of “my eczema is really acting up”. Pt reports that he has had eczema since
infancy, at which point it was severe. Pt reports that CC began approximately 2 weeks ago and has
presented as a rash only on his bilateral lower legs since then. Pt reports itching and burning from
the rash. Pt reports di culty sleeping due to the discomfort of his rash. Pt tried using Aveeno
cream, sx resolved brie y but has since returned. Pt reports “nothing has made it better or worse”
and that he hasn’t been to see any other providers about CC. Pt reports no changes in product
usage and no insect bites. Pt denies smoking, drug use, with social drinking.
Objective:
Pt vital signs presented as a febrile with an axial temp of 98.6 degrees Fahrenheit, BP 116/77 mm
Hg, HR 64 bpm, SpO2 98% RA, RR 13 breaths/min.
WDWN male alert and oriented x4. Pt is 180 cm, 84.1 kg. A ect appropriate with clear speech and
ambulates without assistance. Pt does not appear distressed, is dressed appropriately for the
weather. Pt has red, scaly rash on bilateral lower limbs.
Assessment:
This patient is a 22 yr old male presenting with a recent history of in amed rash on bilateral lower
legs. Clinical examination suggests impaired skin integrity r/t contact with irritants or allergens AEB
rash are up after exposure to grass and pool water.
Plan:
Pt will keep skin clean, dry, and well moisturized. Pt will also continue to use the Aveeno cream as it
previously provided sx relief. Skin culture of rash was taken to r/o possible viral or bacterial
infection.