SOAP note for virtual patient case 1 (1).docx - Trey Bland Virtual Patient#1 SOAP note CC 2 year and 11-month-old female presenting with a rash HPI

SOAP note for virtual patient case 1 (1).docx - Trey Bland...

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Trey Bland Virtual Patient #1 SOAP note CC: 2 year and 11-month-old female presenting with a rash HPI: Elizabeth is a 2 year and 11-month-old female presenting with a purple, non-blanching rash. The rash has been present for the last 5 days and started on the chest but continued to spread throughout the rest of the body. She is fussy, but the parents don’t believe she is itchy. They have given her oatmeal baths and believe that may have helped. She also has a fever of 102° F, some possible belly pain, a runny nose, and a possible sore right knee. She is unvaccinated. PMH: She is allergic to penicillin but has no other allergies. She is not currently on any medications. She was born after a normal pregnancy and had no problems at birth. She had an umbilical hernia at the age of 6 months for which the parents taped down and has went away with no other problems. Social Hx: The parents do not smoke. They live in a house with dogs and a cat but are in contact with farm animals on a semi-regular basis. ROS: Patient has not had any eye redness or ear pain. No swelling or lymphadenopathy noted.
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  • Fall '19
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