Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note: Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies be
SUBJECTIVE: Patient is a 4-year-old female with a chief complaint of an itchy rash present since yesterday. The patient’s mother reports that the rash is on the chest and abdomen, red in color with small bumps. She stated that the patient has no known allergies and no medication use at this time. No recent illnesses or travel reported. The patient eats well, sleeps normally and has no other complaints at this time.
OBJECTIVE: Upon examination, the rash was found to be raised, slightly red in color with some fine scaling. There was mild itchiness associated with the rash but no visible signs of infection or inflammation noted.