NURS 6023-Advanced Assessment and Diagnostic Evaluation
STUDENT NAME: _____________________
Date: _____________________5/19/2026____________________
SOAP Note
SUBJECTIVE
“My child has had a rash on face for 5 days”
Chief Complaint
Gus is a 5 year old male who was brought in by his mother to the primary care clinic
with a concern about a rash on his face. Mother states the rash started as small red
bumps five days ago. She says today, the rash spread to around his mouth and lower
part of nose and she noticed yellow drainage from the lesions. Pt reports no pain.
Mother has attempted OCT antibiotic ointment and cleaning with dial soap without
History of relief. Pts mother noted that other kids at school may have had the same rash. Mother
Present Illness denies any previous skin conditions, states pt is still eating well and playing as normal
even with evolving rash.
Review of Systems (Problem-focused)
General Denies, fever, chills, fatigue, or changes in weight
Skin Small red bumps that spread to mouth and nose w/yellow drainage, mild
itching around mouth and nose, denies rash or bumps anywhere else
Head Denies headaches, head injuries, or dizziness
Eyes Denies visual problems, swelling, or itching
Ears Denies hearing problems, tinnitus & infections
Nose Red bumps on outer nose w/ yellow drainage, denies frequent colds & sinus
issues
Mouth/Throat Red bumps around outside of mouth w/ yellow drainage, denies lesions inside
mouth, denies pain in mouth and throat
Cardiovascular Denies chest pain, palpitations
Respiratory Denies shortness of breath, cough, wheezing
Abdomen Denies N/V/D, abdominal pain, reports appetite good
GU
Lymphatic Denies swelling, pain, or lumps
MSK
Neurology
Psychiatric
Past Medical History
, No medical history, UTD on vaccinations, no daily medications
T&A 3/2024,
Past Surgical History
Allergies Peanuts, shrimp, amoxicillin
Medications No medications
Mother (34yr) w/ HTN
Family History Father (36yr) no medical history
Younger sister (3y)
Maternal Grandmother 57yr w/ Diabetes
Maternal grandfather died at 62 yrs from heart attack
Paternal grandmother (62y) w/ no history
Paternal grandfather (60y) Hyperlipidemia
Lives with mother and father, younger sister. He attends preschool Monday-
Social History Friday and looks forward to going. 2 dogs in home. Father smokes cigarettes
outside and not around pt.
OBJECTIVE (Problem-focused)
T:98.9F HR98 BP 84/76 RR22 HT 41” Wt. 42lbs
Vital signs
Physical Exam
General Survey Alert, no signs of discomfort, well-nourished and groomed
Skin Multiple 2-4mm grouped and crusted, golden vesicles surrounded by erythema
with yellow drainage around edges of mouth and nares
Head Normocephalic, atraumatic, no lesions
Eyes Pupils equal and reactive to light, symmetric with normal EOC movements, no
hemorrhages noted, no edema
Ears TMs intact bilaterally without erythema or effusion. External auditory canal
patent, no swelling
Nose Nares patent bilaterally, nasal mucosa pink, multiple 2-4mm honey-crusted
vesicles grouped around nares producing yellow drainage
Mouth/Throat Multiple 2-4mm honey crusted vesicles grouped around edges of mouth.
Oropharynx without erythema or exudate, buccal mucosa pink without lesions,
good dentition, gums pink, not inflamed. Neck supple, trachea midline
Respiratory Breath sounds clear to auscultation in all fields, chest wall expansion
symmetrical, no increased effort of breathing
Cardiovascular Heart regular rhythm and rate. S1 & S2 heard, no murmurs, gallops, or rubs.
Distal pulses are 3+ and symmetrical bilaterally. Cap refill brisk.
Abdomen Soft, nontender, no distention, or masses. No dullness to percussion. Bowel sounds present,
no guarding or rebound noted.
GU
Lymphatics No palpable swelling
MSK Full ROM all extremities, gait normal
Neurologic Mood and affect appropriate for age
Psychiatric
STUDENT NAME: _____________________
Date: _____________________5/19/2026____________________
SOAP Note
SUBJECTIVE
“My child has had a rash on face for 5 days”
Chief Complaint
Gus is a 5 year old male who was brought in by his mother to the primary care clinic
with a concern about a rash on his face. Mother states the rash started as small red
bumps five days ago. She says today, the rash spread to around his mouth and lower
part of nose and she noticed yellow drainage from the lesions. Pt reports no pain.
Mother has attempted OCT antibiotic ointment and cleaning with dial soap without
History of relief. Pts mother noted that other kids at school may have had the same rash. Mother
Present Illness denies any previous skin conditions, states pt is still eating well and playing as normal
even with evolving rash.
Review of Systems (Problem-focused)
General Denies, fever, chills, fatigue, or changes in weight
Skin Small red bumps that spread to mouth and nose w/yellow drainage, mild
itching around mouth and nose, denies rash or bumps anywhere else
Head Denies headaches, head injuries, or dizziness
Eyes Denies visual problems, swelling, or itching
Ears Denies hearing problems, tinnitus & infections
Nose Red bumps on outer nose w/ yellow drainage, denies frequent colds & sinus
issues
Mouth/Throat Red bumps around outside of mouth w/ yellow drainage, denies lesions inside
mouth, denies pain in mouth and throat
Cardiovascular Denies chest pain, palpitations
Respiratory Denies shortness of breath, cough, wheezing
Abdomen Denies N/V/D, abdominal pain, reports appetite good
GU
Lymphatic Denies swelling, pain, or lumps
MSK
Neurology
Psychiatric
Past Medical History
, No medical history, UTD on vaccinations, no daily medications
T&A 3/2024,
Past Surgical History
Allergies Peanuts, shrimp, amoxicillin
Medications No medications
Mother (34yr) w/ HTN
Family History Father (36yr) no medical history
Younger sister (3y)
Maternal Grandmother 57yr w/ Diabetes
Maternal grandfather died at 62 yrs from heart attack
Paternal grandmother (62y) w/ no history
Paternal grandfather (60y) Hyperlipidemia
Lives with mother and father, younger sister. He attends preschool Monday-
Social History Friday and looks forward to going. 2 dogs in home. Father smokes cigarettes
outside and not around pt.
OBJECTIVE (Problem-focused)
T:98.9F HR98 BP 84/76 RR22 HT 41” Wt. 42lbs
Vital signs
Physical Exam
General Survey Alert, no signs of discomfort, well-nourished and groomed
Skin Multiple 2-4mm grouped and crusted, golden vesicles surrounded by erythema
with yellow drainage around edges of mouth and nares
Head Normocephalic, atraumatic, no lesions
Eyes Pupils equal and reactive to light, symmetric with normal EOC movements, no
hemorrhages noted, no edema
Ears TMs intact bilaterally without erythema or effusion. External auditory canal
patent, no swelling
Nose Nares patent bilaterally, nasal mucosa pink, multiple 2-4mm honey-crusted
vesicles grouped around nares producing yellow drainage
Mouth/Throat Multiple 2-4mm honey crusted vesicles grouped around edges of mouth.
Oropharynx without erythema or exudate, buccal mucosa pink without lesions,
good dentition, gums pink, not inflamed. Neck supple, trachea midline
Respiratory Breath sounds clear to auscultation in all fields, chest wall expansion
symmetrical, no increased effort of breathing
Cardiovascular Heart regular rhythm and rate. S1 & S2 heard, no murmurs, gallops, or rubs.
Distal pulses are 3+ and symmetrical bilaterally. Cap refill brisk.
Abdomen Soft, nontender, no distention, or masses. No dullness to percussion. Bowel sounds present,
no guarding or rebound noted.
GU
Lymphatics No palpable swelling
MSK Full ROM all extremities, gait normal
Neurologic Mood and affect appropriate for age
Psychiatric
