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
Expert Solution Preview
Introduction:
Atopic Dermatitis Disease is a chronic inflammatory skin condition characterized by pruritus, eczematous lesions, and xerosis. It is a common skin problem affecting a significant number of individuals worldwide. The cause of Atopic Dermatitis is unknown, but studies suggest that it may be related to genetic and environmental factors. As a medical professor, it is important to train medical college students on how to conduct assessments and create a plan for patients with Atopic Dermatitis Disease.
Answer:
SOAP Note For Patient Diagnosed With Atopic Dermatitis Disease
Subjective:
Chief Patient Complaint: The patient, a 5-year-old male, presents with a complaint of itchy skin rash on his arms and legs.
PMH: The patient has no significant past medical history of Atopic Dermatitis Disease.
PSH: The patient has no past surgical history.
FH: The patient’s family history is positive for allergies, asthma, and Atopic Dermatitis Disease.
SH: The patient lives with his parents and siblings and attends kindergarten. No significant social history was elicited.
ROS: The patient has a history of eczematous skin rashes and pruritus on his legs and arms. The patient reports no history of fever, joint pain, respiratory or gastrointestinal symptoms.
Objective:
Vital Signs: Blood pressure 100/60 mmHg, heart rate 100 beats/minute, respiratory rate 20 breaths/minute, and temperature 98.6°F. BMI is within normal range.
Skin Exam: The patient has multiple erythematous, scaly patches of varying sizes on his legs and arms, consistent with Atopic Dermatitis Disease. The lesions are excoriated with mild weeping.
Lab Tests: No lab tests are required at this time.
Allergies: The patient has no allergies.
Assessment:
Diagnosis: Atopic Dermatitis Disease (ICD-10 Code: L20.81).
Differential Diagnosis:
1. Psoriasis (ICD-10 Code: L40.9): This differential was considered because of the presence of erythematous, scaly patches.
2. Contact dermatitis (ICD-10 Code: L23.9): This differential was considered because of the patient’s recent exposure to new clothing and his rash symptoms.
3. Scabies (ICD-10 Code: B86): This differential was considered because of the excoriated, weeping nature of the patient’s lesions.
Plan:
Self-Assessment & Clinical Guidelines: The plan of care will involve topical corticosteroids for the patient’s Atopic Dermatitis Disease, as well as educating the patient and his parents on moisturizing and healthy lifestyle measures. Additionally, an allergy test will be recommended to help identify possible allergens and triggers.
Analysis of S+O Data: The patient’s S+O data supports the diagnosis of Atopic Dermatitis Disease, with a significant family history and clinical features consistent with the condition. Using evidence-based clinical reasoning and guidelines, the plan of care was developed to address the patient’s symptoms, improve his quality of life, and prevent complications.