Already started but need help filling out the highlighted areas at the bottom( ON THE ATTACHMENT BUT UNDERLINED ON THIS BOX) 
Diagnosis: Tinea Capitis
Plan:
Pharm Interventions:
Non pharm interventions:
Diagnostic testing:
Education:
Follow up:
and immediately available diagnostic results with interpretation
Correctly lists all diagnoses including differentials (if applicable); Comprehensive plan of care including pharm and non-pharm interventions, diagnostic testing, education, and follow up
Skin Assessment
Pt. Initials: HH
Date:7/6/2022
Age:8
Gender: M
S:
Cc “I’m itchy by my hair”
HPI 8-year-old African American male who presents to the office with his father
and mother, with CC of itching on head/hair line. Pt’s mother states she first noticed the
rash about 1 week ago and has been applying Desitin and Neosporin on it 2 x a day with
no improvement. Patient denies pain or tenderness. Patient states sometimes it itches
especially when he goes outside. No other complaints. Patient/mother states this is the
first time he has ever had this happen. Patient’s mother denies being around anyone with
a skin condition or any chemicals or changes in environmental that she is aware of.
Mother denies any recent changes in body soap, laundry detergent, or lotion. Mother
denies any other rashes, lumps, or itching. Denies other skin, nails, or hair changes.
Patient denies allergies and no new animals in the home.
PMH- Patient has no past medical history. Patient’s mother concurs.
Allergies- NKA Mother concurs
Medications- Denies RX medications
OTC or herbal/ Vitamins: Denies taking OTC medications, herbal, supplements,
or vitamins.
Surgeries: No previous surgeries
Vaccinations: Denies Flu, pneumonia (patient has had all child mandated
vaccines per CDC up to his age)
Last Exams: Patient seen at this office for his 5-year-old Well visit last month. Pt
also sees pediatric dentist twice a year. (Last exam 2 months ago)
Psychiatric history: Denies history of depression, anxiety, or any other
psychiatric history
ETOH: Denies drinking alcohol
Tobacco: denies tobacco use
Illegal Drugs: Denies ever using illegal drugs
Occupation/Status: Patient was in VPK last school year and now in summer
camp. Patient will be going to/kindergarten this year.
Sleep Pattern: Pt states he sleeps about 10 hours a day
Exercise History: Mother and father report he has always “been a very active
boy and enjoys playing outside”. Parents state patient plays outside with neighbors and
cousins after summer camp and on the weekends.
Nutrition:
Last 24-hour diet recall: Breakfast: Cereal Lunch: McDonalds 4-piece happy meal with a
Sprite. Dinner: Pizza. Snack: Chips, Apple. Drinks 2glasses of Milk a day, Juice, and
water.
FH: Patient denies any family history of atopic dermatitis, Asthma, throat/mouth/thyroid
cancer, or skin disorders
Paternal Grandfather, 52, DM
Paternal Grandmother, 52, Hyperlipidemia, DM
Maternal grandfather; living 50y/o, HTN
Maternal grandmother; Living 48, HTN, Obese
Father: 27 years old, living, No pertinent medical history
Mother, 28 years old, living, Obese, Hyperlipidemia
ROS
O:
General appearance: Patient was sitting in exam room AAOX4, no distress noted,
Friendly and talkative for age. Both mother and father in the room and good historians.
Skin color appropriate for race. Patient was well groomed. Appears to have healthy
hygiene.
Vital signs: BP Left arm sitting 100/62, HR 90 Apical Sinus Rhythm, Resp 19 Regular
non labored and even, Temp 97.3 Temporal, O2 sat 100% on room air, denies pain at this
time.
Denies fever, fatigue, or malaise. 50inches, 57lbs, denies weight changes. Appetite good.
BMI 16 (55%) Healthy weight
HEENT:
Head/Neck: Denies any lymph node pain, goiters, swelling, nodules, headaches,
head trauma, dizziness, light headiness, or sinus pressure.
Eyes: denies eye pain, vision changes, itchy or discharge. Denies wearing
corrective lenses
Ears: denies changes in hearing, ringing, pain, or discharge.
Nose: denies pain, nose bleeds, polyps, loss of smell, or hay fever.
Mouth/Throat denies sore throat, difficulty swallowing, loss of taste, gum
bleeding, carries or lesions. Denies TMJ
Respiratory: denies SOB, cough, asthma, nasal discharge, allergies, or swollen
glands.
GI: denies heartburn or indigestion, constipation, vomiting, nausea, diarrhea,
masses, hernias, or bowel changes.
Skin: C/o rash on scalp denies any other rashes, cyanosis, clubbing of fingers,
night sweats, or changes in nails or hair
Physical Assessment:
Head:
Inspection: 3 annular lesions noted along right side of hair line. Normocephalic,
symmetric, clear of scars, acne, no drooping, no weakness, or involuntary movement.
Palpation/Auscultate: Erythematous plaques annular shape and scaling border
noted and felt. Mandible is symmetric with no cracks or pops during palpations when
assessing TMJ and having patient open mouth (with fingers by the tragus of the ear)
Lymph nodes are non-palpable and non-tender. Temporal artery no bruits
Neck:
Inspection: Accessory muscles symmetrical while head erect and still and
trachea(midline) on observation. Lymph nodes not swollen on inspection. Supple with
full ROM. Face symmetrical, no drooping
Palpation: Lymph nodes are non-palpable and non-tender. Thyroid is soft and
smooth on palpation with proper upward movement when swallowing (Standing behind
pt, had pt tip head forward and toward the side to be examined and swallow). Thyroid
moves up into assessors’ fingers when swallowing bilaterally. Carotid arteries +3/4 with
palpation on one side at a time.
Auscultation: Trachea no stridor, Carotid arteries no bruits, Thyroid no bruit
Eye:
Visual Acuity: Snellen 20/20 bilaterally, EOM intact,
Visual fields normal by confrontation (standing 2 feet away-looking into eyes at
eye level- flickering finger until they can see / cover one eye at a time)
Corneal light reflex- symmetric bilaterally. (Shines light 12in away while pt looks
straight ahead).
Cover- uncover test: no weakness noted / gaze remained normal (pt stares straight
at nose, cover one eye at a time)
Cardinal Fields of gaze-Tracking of object with both eyes
Inspection: no papilledema, conjunctiva- pink, moist, clear, Sclera white. No
crusting or drainage around tear ducts/eyelids. Brows and lashes present. Cornea and lens
smooth.
Palpation: eversion of upper lids, no color change, swelling or lesions
Funduscopic: PERRLA, Red reflex present bilaterally, macula is approximately
2.5 disc flat with sharp margins. Vessels present. No crossing defect, retinal background
even with no hemorrhages or exudate, macula even color bilaterally.
Ear:
Hearing test:
Whisper test- passed- patient able to hear whispered words bilaterally
from 2 feet away with one ear covered at a time

Rinne- AC>BC bilaterally (using the tuning fork placed behind ear on
bone, tell me when it stops, move to the front of the auricle, and tell me if you can still
hear it)
Weber- not lateralized (using the tuning fork, tell me which ear or both
that you hear it in)
Inspection: External- symmetric bilaterally, no drainage, bruising, edema, or
erythema noted.
Palpate: no tenderness or pain. (Pushed on tragus and mastoid bone)
Otoscopic: TM bilaterally pearly gray with light reflex and landmarks intact, no
perforations, no foreign bodies. Mild ear wax noted bilaterally. Inspected internal ear and
malleus (short process and handle)
Nose :
Inspection : External- Symmetric, no drainage, polyps, or secretions observed
Patency : Internal- Nares patent, septum midline and symmetric. Mucousa
pink and dry
Sinus :
Palpation/ Transillumination : Non tender, no edema. Normal transillumination
(using the light)
Mouth:
Inspect & Palpate: Can clench teeth
Breath: No halitosis
Lips: moist, not cracked, no erythema or sores
Tongue: midline, pink and smooth, no lesions
Buccal mucosa: moist, pink, no edema
Gums: moist, pink, no edema, or sores/ulcers
Teeth: straight with good dentition
Uvula: midline, rises on phonation
Throat/Tonsils: Pink mucosa, no lesions, or exudate/ Tonsils grade 0 with no
spots or lesions observed
Gag reflex present
Skin:
Presence of 3 annular lesions noted along right side of hair line.
Erythematous plaques annular shape and scaling border noted and felt on palpation. No
other lesions or rashes noted on neck, trunk, or other body parts. No warts or moles noted
on skin.
Differentials: Atopic Dermatitis, Plaque Psoriasis, Impetigo
Diagnosis: Tinea Capitis
Plan:
Pharm Interventions:
Non-pharm interventions:
Diagnostic testing:
Education:
Follow-up:
SOAP DISCUSSION BOARD GRADING RUBRIC
Total Possible Points: 15
Criteria
Distinguished (2.5)
Proficient (2)
Basic (1.5)
Minimal (0)
Original post:
Initial SOAP note is
generally accurate,
problem-focused,
and thorough yet
omits unnecessary
information;
correctly
differentiates
subjective and
objective data. No
patient identifiers.
Initial SOAP is
generally thorough
but lacks some
accuracy or detail;
includes some
unrelated or
unnecessary
information; one or
two errors
differentiating
subjective and
objective data
Initial SOAP is very
limited in accuracy
or detail and fails to
assess presenting
complaint with
relevant subjective
and objective data
Initial DB post is
not submitted on
time or is not done
at all.
Includes all pertinent
patient history and
physical exam
elements related to
presenting
complaint: CC,HPI,
PMH/PSH,
Allergies, Meds, FH,
Soc. Health
Promotion, and ROS
; PE and immediately
available diagnostic
results with
interpretation
Includes some
unnecessary
subjective and
objective data or
omits some relevant
subjective and
objective data
Omits significant
and relevant
subjective and
objective data or
includes majority of
unnecessary data
Omits all subjective
and objective data
Correctly lists all
diagnoses including
differentials (if
applicable);
Comprehensive plan
of care including
pharm and nonpharm interventions,
diagnostic testing,
education, and
follow up
Primary or actual
diagnosis is correct;
omitted active,
chronic problems or
differentials; plan of
care lacks one or
two of the items
listed in first
column
Primary or actual
diagnosis is
incorrect or not
supported by
subjective an
objective findings;
Omits assessment
and plan of care
SOAP note of an
actual patient
encounter with
acute or chronic
problem
Original Post:
Subjective Data
and Objective
Data
Original Post:
Assessment and
Plan
plan of care does
not relate to
diagnosis or lacks
three or more of
items listed in first
column
Criteria
Distinguished (2.5)
Proficient (2)
Basic (1.5)
Minimal (0)
Response Posts
Responses (2 or
more) are thoughtful,
substantive, on topic,
and advance
knowledge of
diagnosis, and offers
alternative plan of
care. Notes strengths
of SOAP
documentation, areas
of improvement such
as any omitted
information
Responses (2 or
more) lack one of
the following:
strength of
documentation, area
of improvement, or
alternative plan of
care
Only 1 response is
made but it is
thoughtful and
contributes to the
discussion. Includes
strengths, areas for
improvement, and
alternative plan of
care.
No responses are
submitted within
the time limits.
Both Original and
Response Posts:
Interventions
outlined in plan of
care for original and
suggested
alternatives for
response posts
supported with
evidence from
current, relevant,
scholarly, peerreviewed sources
including but not
limited to textbooks,
practice guidelines,
and scientific
journals. APA
format for reference
citations
Part of plan
supported by
scientific evidence,
appropriate APA
format
Plan of care on
either the original or
response posts not
supported with
scientific evidence;
references not cited
in APA format.
No documentation
of evidence based
plan of care using
APA format.
All posts are
mechanically and
grammatically
correct, using
concise medical
terminology and
format; APA style
for citations; posts
and responses are
respectful.
Postings contain 1-3
spelling, grammar,
or punctuation
errors; postings and
responses are
mostly respectful in
tone.
Postings contain 4-6
spelling, grammar,
or punctuation
errors; postings and
responses border on
disrespect and
sarcasm.
Postings contain
more than 6
spelling, grammar,
or punctuation
errors; postings and
responses are not
respectful in tone.
Evidence Based
Plan of Care
Grammar, Style,
& Netiquette

Purchase answer to see full
attachment