Description
Please fallow instruction. I need you to make up a soap note using the template for a 5 years male patient diagnose with Atopic Dermatitis Disease. APA style.
Please and fill out the template completely using your own words for the assessment finding. Fallow the format of the Soap Note, which I sent to you as an attachment. I included the empty soap note template you must plug the information in it. I need you to provide the following: APA format with at least with 5 references no older than 5 years old.
Chief patient compliant
Present Medical Assessment (PMH)
Pass Medical Assessment (PSH)
Family History (FH)
Social History (SH)
Review Of System (ROS) completed. Provide complete and concise summary of pertinent information.
The Diagnosis: Atopic Dermatitis Disease ICD 10 code
3 differential diagnoses with ICD 10 code describe and discuss why choosing them
3 Complete vital sign, BMI
Subjective Information
Complete Objective Information
Lab Tests
Allergies
Complete physical exam with critical elements related to subjective data.
Perform Assessment
Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Create a Plan
Self-Assessment & Clinical Guidelines
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
B) Discuss Atopic Dermatitis Disease
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Explanation & Answer
H
Pediatric SOAP Note
Name: Lawrence Smith
Date: 18/05/2018
Sex: Male
Age/DOB/Place of Birth: 5 years
SUBJECTIVE
Historian:
Present Concerns/CC
The front of the elbows and the back of the knees are affected by the disease. Lawrence is frequently
itching and therefore the front of the elbows is red. I clearly observed the swollen and cracked skin.
Child Profile:
Lawrence is a 5 years old male patient with Atopic Dermatitis disease.
HPI:
From the medical history of Lawrence seen from the Electronic Medical Records, he has never suffered
from this disease. The mother said that she noticed there was a problem recently as she bathed her baby.
Medications
Lawrence is currently using steroid cream where the mother applies the cream on Lawrence’s affected
areas.
PMH:
Allergies: The patient is allergic to pet dander and to soaps and lotions with heavy fragrance.
Medication Intolerances: The patient responded well to all medication.
Chronic Illnesses/Major traumas: The patient had no chronic illness
Hospitalizations/Surgeries: No records of surgery.
thoracotomy Immunizations: None
Pediatric SOAP Note
Family History:
The older sister of Lawrence has had this disease when she was at the age of Lawrence. She was treated
and she responded positively to the medication. She is moving on well and has not shown the signs of
Atopic Disease again. Her parents are supportive in ensuring she did not use any allergens that would
worsen the condition. The mother explained that the mother-in law has had this disease in 2010 though
she went through medication at a late stage and therefore she was diagnosed with asthma.
Social History:
Lawrence lives with his parents and his sister, Angela, in an...
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