SOAP NOTE: SCABIES 1 SOAP Note: SCABIES 2 SCABIES Miami ✓ Solved
Patient: F.D. Age: 48 years old Race: Hispanic Gender: Male Insurance: Private insurance.
SUBJECTIVE
Chief complaint: "My skin itches a lot at night."
History of present illness (HPI): Patient is a 48-year-old Hispanic male reporting a week of itching in the internal fold of elbows and legs, significantly interfering with sleep. He has lived in a shelter for two months. Denies dermatitis history and has not used OTC products.
Past Medical History (PMH): Last annual exam in January. Chronic Condition: Essential Hypertension (controlled). Current Medication: Enalapril 20 mg PO QD. No hospitalizations or mental health issues. Surgery: Cholecystectomy seven years ago. No recent exposures to HIV or blood transfusions. Environmental exposures are negative. Immunizations are up to date, with the last flu vaccine received on 01/23/2019.
Exercise: Engages in daily exercises. Diet: Describes a healthy diet rich in whole grains, vegetables, and fruits.
Social History: Single, lives with mother. Good family relations. Denies drug, alcohol, or tobacco use. Educational level: Middle School. Sexual Behavior: Heterosexual, one partner last year, always uses condoms, no STD risk. Allergies: NKDA.
Family Medical History: Mother (75 y/o) with HTN and diabetes; father unknown. Review of Systems: Systemic symptoms include itchy skin.
No other systemic symptoms reported.
OBJECTIVE
Physical Exam: Vitals: BP 120/80 mmHg, Pulse 78 bpm, Respiration 15 per min, Temp 98.1 F, Height 70 in, Weight 188 lbs, BMI 29.1. Patient appears alert, hydrated, and in no distress.
Skin: Presence of burrows and vesicles in internal elbows, knees, and thighs. Excoriated papules noted.
ASSESSMENT
Primary Diagnosis: B86 Scabies, due to infestation by Sarcoptes scabiei. Characterized by intense pruritus, mainly at night, and typical distribution patterns. Differential Diagnosis: Atopic dermatitis, impetigo, folliculitis. Other findings include controlled essential hypertension and overweight (ICD E66.3).
PLAN
Therapeutic: Permethrin 5% cream, applied from neck to soles once; removed after 8-14 hours, repeat in two weeks. Hydroxyzine 25 mg BID for five days.
Non-Therapeutic: Educated about treating sexual and household contacts simultaneously to avoid reinfestation. Instructed to wash bedding and clothing at 140°F or higher immediately post-treatment. Items that can’t be washed should be sealed for a week.
Follow-ups: Scheduled for three weeks. Patient advised to return if symptoms worsen.
Paper For Above Instructions
Scabies, a parasitic infestation caused by the mite Sarcoptes scabiei, presents clinically with an array of symptoms, predominantly characterized by severe itching. This condition often necessitates thorough evaluation and management directives to mitigate patient discomfort while preventing further transmission. This SOAP note details a patient case that exemplifies pertinent aspects of clinical assessment and management.
The submission of the SOAP note contains various components, including subjective data, objective findings, assessment of the condition, and an appropriate plan for treatment. The subjective portion reveals an essential narrative of the patient's immediate concerns and medical history, while the objective section provides measurable diagnostic data critical for driving therapeutic decisions.
The patient, identified as F.D., is a 48-year-old Hispanic male who presents a troubling chief complaint regarding highly pruritic skin, notably intensifying at night. The significant itchiness, affecting internal bodily folds, serves as the cornerstone symptom. An interesting factor was the patient's housing situation, having lived in a shelter, which could have facilitated close contact with others and increased the risk of infestation.
In reviewing the patient’s history, it is crucial to highlight the absence of prior dermatological issues, which steers the focus towards scabies as a primary differential diagnosis rather than atopic dermatitis or other skin conditions. This history becomes vital, as chronic skin conditions can complicate or mask scabies symptoms.
On examination, clinical signs indicative of scabies were confirmed, including the presence of burrows, vesicles, and excoriated papules in the relevant body areas. Such findings help to solidify the diagnosis of scabies rather than alternative dermatologic conditions. Furthermore, the objective assessment confirmed vital signs were within normal ranges; thus, he did not present any immediate systemic concerns.
The assessment confirmed the primary diagnosis of scabies (ICD code B86), while also identifying an essential hypertension condition being controlled by medication and overweight status. These comorbidities necessitate consideration in determining a holistic treatment approach.
The planned treatment strategy consists of the application of Permethrin 5% cream, known for its effectiveness against scabies by suffocating the mites. Coupled with this pharmacological approach, Hydroxyzine 25 mg Bid was prescribed for symptomatic relief of itching. Education surrounding the importance of treating household and sexual contacts simultaneously is a fundamental public health measure to curtail the spread of infestation. Additionally, proper sanitation measures for fabrics and clothing post-treatment will mitigate risks for reinfestation.
Finally, the patient has been instructed to return for a follow-up appointment in three weeks or sooner if symptoms worsen. This guidance reinforces the dynamic nature of managing such cases and emphasizes the importance of continuous care in dermatological practice.
References
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