SOAP Note
Develop a SOAP note for a 12-year-old boy who presents with a dog bite. The boy discovered the bite this morning. The skin seems to be getting worse. The boys’ mothers are worried it might be something terrible. In your SOAP note, be sure to address questions that you would ask and how you would diagnose and treat the children.
Sample Paper
SOAP Note
| Name: X.M. Age:12 Sex: Male |
| SUBJECTIVE |
| CC:
“I had a dog bite and the skin is changing” |
| HPI:
The patient is a 12-year-old who is brought to the clinic by the mother. The boy discovered he had a dog bite this morning, and the skin seems to be getting worse. |
| Medications: no current medications.
Drug allergy: NKDA |
| Family History: Both parents are alive. |
| Social History; Both the parents are alive, and the patient lives with them. |
| ROS |
| General; The patient is 12-years old. No fever, chills, |
| Skin; Redness and swelling around the bite region. |
| Eyes; No blurred or double vision, no visual loss or yellowing of the sclerae.
Ears; nor hearing loss or pain. Nose/Mouth/Throat; Nose; no runny nose, sneezing, or congestion. Throat; no sore throat reported. |
| Cardiovascular; Regular rhythms, no murmurs, no chest pain, edema, or other discomforts. |
| Respiratory; No shortness of breath or cough |
| Gastrointestinal; Normal bowel sounds, no abdominal pain noted. |
| Genitourinary/Gynecological; No burning during urination odor or odd colors were reported. |
| Musculoskeletal; Muscle stiffness around the bite region. |
| Neurological; There are no headaches, tingling in the hands or legs, dizziness, paralysis, slurring of speech, or ataxia. No changes in bladder and bowel movements. |
| Heme/Lymph/Endo; No reports of sweating, heat intolerance, polyuria, or polydipsia. No enlarged lymph nodes. No bruising, anemia, or bleeding. |
| Psychiatric; No mental issues were identified |
| Objective |
| General Appearance; The patient is male; he is appropriately dressed and appears his age. |
| Skin; Bruises were noted around the left leg. Otherwise, the skin is dry, warm, and intact. |
| HEENT; No blurred or double vision, no visual loss or yellowing of the sclerae. Ears; nor hearing loss or pain. Nose; no runny nose, sneezing, or congestion. Throat; no sore throat observed. |
| Cardiovascular; Regular rhythms, no murmurs, no chest pain, edema, or other discomforts. |
| Respiratory; No shortness of breath or cough. |
| Gastrointestinal; Normal bowel sounds. No masses or abnormal bowel movements. |
| Musculoskeletal; Muscle stiffness around the bite region. |
| Neurological; There are no headaches, tingling in the hands or legs, dizziness, paralysis, slurring of speech, or ataxia. No changes in bladder and bowel movements. |
| Psychiatric; No mental issues were identified. |
| Diagnosis |
| · The diagnosis for this patient would be based on physical examination and the history of the present illness. The physical examination will involve examining the bite area to identify characteristics of the bite, including redness, swelling, pus, red streaks spreading from the bite area, and pain.
· Some of the questions to ask the patient would include; Do you own the dog? When did the bite occur? Is the dog vaccinated against rabies, or is it possible to capture the dog? Did the dog show any signs of disease or abnormal behavior? (Horswell & Sheikh, 2021). |
| Treatment plan |
| · The treatment should involve irrigating the wound with sterile saline, and visible debris from the wound should be removed.
· Topical antibiotic agents should then be applied to prevent infections development on the wound. The wound, however, should not be closed to ensure that it is easily monitored in case infections develop. · The patient should receive some pain killer to manage the pain. · If the patient’s family cannot locate the dog, it would be important to consider a rabies vaccine for the boy just in case the dog had rabies and had not been vaccinated. · The tetanus vaccine is effective for about 10 years, and therefore if he was vaccinated at 3years, there would be no need for another vaccination against tetanus (Jakeman et al., 2020). |
