NURS 6023-Advanced Assessment and Diagnostic Evaluation
STUDENT NAME: ________Neely_Smothers_______________
Date: _______________05/30/26___________________
SOAP Note
SUBJECTIVE
Chief Complaint Worsening facial rash for 5 days
G.S. is a 5 year old male accompanied by his mother with concerns of a rash
to his face. She first noticed the rash when picking the child up from school 5
days. She reports the rash started as small red bumps on upper lip that has
now spread around his mouth and lower nose area. She has noticed G.S.
scratching and picking at the rash at times. He reports the rash itching
History of Present sometimes and burning after scratching. Mother attempted over the counter
Illness antibiotic ointment and cleaning with dial soap at night without any
improvement. Other children at his school have recently had similar rashes.
He reports 2/10 severity using Wong-Baker FACES. Mother states that he is
drinking and eating normally.
Review of Systems (Problem-focused)
General Denies fever, chills, fatigue, or decreased appetite.
Skin See HPI; Reports localized itching, denies body rashes
Head Denies headaches, dizziness, or trauma.
Eyes Denies any redness, drainage, or vision changes.
Ears Denies hearing changes, pain, or drainage
Nose See HPI; Denies cough, rhinorrhea, or congestion
Mouth/Throat Denies internal oral lesions, sore throat, or difficulty swallowing
Cardiovascular Denies CP
Respiratory Denies cough, congestion, or shortness of breath
Abdomen Deferred
GU Deferred
Lymphatic Deferred
MSK Deferred
Neurology Deferred
Psychiatric Deferred
Mother denies any pertinent medical history. G.S. is rarely sick and generally
Past Medical a healthy child. Age appropriate immunizations are up to date.
History
, Circumcision at 7 days old
Past Surgical
History
No known allergies to medications, food, or environment.
Allergies
Medications Neosporin- thin layer topically 3 times a day as needed
Mother – 33 years old, alive and well.
Family History Father – 33 years old, alive and well.
Maternal grandmother – 62 years old, alive and well, past medical history of
HTN and alcohol addiction.
Maternal grandfather – 63 years old, alive and well, no known medical
history.
Paternal grandmother – 66 years old, alive and well, past medical history of
CAD and CVA.
Paternal grandfather –65 years old, alive and well, past medical history of
HTN.
Only child who lives in a single family home with his mother and father. The
Social History mother is the primary caregiver during this visit. Both parents work full time.
There are no reported household pets. She has not changed laundry detergent,
soaps, or lotions. He attends kindergarten at Brookland Elementary where
other kids have recently had similar rashes. Mother denies use of tobacco,
alcohol, recreational or illicit drugs by her or his father. States He is not
exposed to secondhand smoke by any relatives. He is an energic child who
enjoys playing with his school friends.
OBJECTIVE (Problem-focused)
T 98.1, BP 84/76, HR 98, RR 22, HT 41”, WT 42 lbs, Pain 2/10
Vital signs
Physical Exam
General Survey Well-nourished, well-developed male child. He is alert and actively playing.
There are no signs of acute distress.
Skin Multiple honey crusted erythematous lesions to upper lip and perinasal area,
No other lesions or erythema noted.
Head Normocephalic, atraumatic. No scalp lesions or localized swelling
Eyes PERRLA, conjunctiva clear, sclera without injection, No periorbital edema,
drainage, or erythema.
Ears Bilateral tympanic membranes are pearly gray, no bulging or erythema
Nose Nares patient, no internal mucosal erythema, swelling or lesions
Mouth/Throat Oral mucosa pink and moist. No tonsillar enlargement, drainage, or internal
oral lesions.
Respiratory Respiratory rate even and nonlabored. Bilateral lung sounds clear, no
STUDENT NAME: ________Neely_Smothers_______________
Date: _______________05/30/26___________________
SOAP Note
SUBJECTIVE
Chief Complaint Worsening facial rash for 5 days
G.S. is a 5 year old male accompanied by his mother with concerns of a rash
to his face. She first noticed the rash when picking the child up from school 5
days. She reports the rash started as small red bumps on upper lip that has
now spread around his mouth and lower nose area. She has noticed G.S.
scratching and picking at the rash at times. He reports the rash itching
History of Present sometimes and burning after scratching. Mother attempted over the counter
Illness antibiotic ointment and cleaning with dial soap at night without any
improvement. Other children at his school have recently had similar rashes.
He reports 2/10 severity using Wong-Baker FACES. Mother states that he is
drinking and eating normally.
Review of Systems (Problem-focused)
General Denies fever, chills, fatigue, or decreased appetite.
Skin See HPI; Reports localized itching, denies body rashes
Head Denies headaches, dizziness, or trauma.
Eyes Denies any redness, drainage, or vision changes.
Ears Denies hearing changes, pain, or drainage
Nose See HPI; Denies cough, rhinorrhea, or congestion
Mouth/Throat Denies internal oral lesions, sore throat, or difficulty swallowing
Cardiovascular Denies CP
Respiratory Denies cough, congestion, or shortness of breath
Abdomen Deferred
GU Deferred
Lymphatic Deferred
MSK Deferred
Neurology Deferred
Psychiatric Deferred
Mother denies any pertinent medical history. G.S. is rarely sick and generally
Past Medical a healthy child. Age appropriate immunizations are up to date.
History
, Circumcision at 7 days old
Past Surgical
History
No known allergies to medications, food, or environment.
Allergies
Medications Neosporin- thin layer topically 3 times a day as needed
Mother – 33 years old, alive and well.
Family History Father – 33 years old, alive and well.
Maternal grandmother – 62 years old, alive and well, past medical history of
HTN and alcohol addiction.
Maternal grandfather – 63 years old, alive and well, no known medical
history.
Paternal grandmother – 66 years old, alive and well, past medical history of
CAD and CVA.
Paternal grandfather –65 years old, alive and well, past medical history of
HTN.
Only child who lives in a single family home with his mother and father. The
Social History mother is the primary caregiver during this visit. Both parents work full time.
There are no reported household pets. She has not changed laundry detergent,
soaps, or lotions. He attends kindergarten at Brookland Elementary where
other kids have recently had similar rashes. Mother denies use of tobacco,
alcohol, recreational or illicit drugs by her or his father. States He is not
exposed to secondhand smoke by any relatives. He is an energic child who
enjoys playing with his school friends.
OBJECTIVE (Problem-focused)
T 98.1, BP 84/76, HR 98, RR 22, HT 41”, WT 42 lbs, Pain 2/10
Vital signs
Physical Exam
General Survey Well-nourished, well-developed male child. He is alert and actively playing.
There are no signs of acute distress.
Skin Multiple honey crusted erythematous lesions to upper lip and perinasal area,
No other lesions or erythema noted.
Head Normocephalic, atraumatic. No scalp lesions or localized swelling
Eyes PERRLA, conjunctiva clear, sclera without injection, No periorbital edema,
drainage, or erythema.
Ears Bilateral tympanic membranes are pearly gray, no bulging or erythema
Nose Nares patient, no internal mucosal erythema, swelling or lesions
Mouth/Throat Oral mucosa pink and moist. No tonsillar enlargement, drainage, or internal
oral lesions.
Respiratory Respiratory rate even and nonlabored. Bilateral lung sounds clear, no
