SOAP Note: Scabies 1 And 2

Question

SOAP NOTE: SCABIES 1 SOAP Note: SCABIES 2 SCABIES Pat Patient Information Patient: F.D. Age: 48 years old Race: Hispanic Gender: Male Insurance: Private insurance. Subjective Chief complaint: “My skin itches a lot at night.” History of Present Illness (HPI): The patient is a 48-year-old Hispanic male reporting a week of significant itching in the internal folds of his elbows and legs that has hindered his sleep. He has recently lived for two months in a shelter with his mother and denies any past history of dermatitis or atopy. He is not using any OTC creams or lotions, and he notes that the skin lesions and itching have worsened. Past Medical History (PMH): Last annual physical exam in January. Chronic condition: Essential Hypertension, controlled with current treatment. Current medication: Enalapril 20 mg PO QD. No hospitalizations or significant medical procedures reported. No history of mental illness or physical trauma in the last year. Surgery: Cholecystectomy 7 years ago. Environmental Exposure: Patient lived in a shelter for two months due to resolved economic issues. Denies known HIV exposure, blood transfusions, or exposure to hazardous materials. Immunizations: Up to date (Flu Vaccine: 01/23/2019). Exercise: Engages in regular daily exercise. Diet: Reports a "healthy" diet rich in whole grains, vegetables, fruits, and proteins. Social History: Single, lives with mother. Positive family relationships and denies substance use. Educational level: Middle School. Heterosexual; one sexual partner in the past year with consistent condom use; denies STD risk behaviors. Allergies: No known drug or food allergies. Family Medical History: Mother (75 y/o) has hypertension and diabetes; father’s medical history is unknown. Review of Systems: The patient has systemic skin itchiness with no accompanying chills, weight loss, or other symptoms. Neurological, psychological, and other systemic reviews are normal. Objective Physical Exam: Vitals show BP 120/80 mmHg, pulse 78

Dr. Jack HW Helper · Accepted Answer

Scabies is a common parasitic skin condition caused by the mite Sarcoptes scabiei. It is characterized by intense itching, especially at night, and results in a distinctive rash. The present case highlights a 48-year-old Hispanic male patient experiencing significant nighttime pruritus localized primarily in the folds of skin. This presentation is typical, as scabies often flourishes in areas where skin-to-skin contact occurs, making the diagnosis clinically pertinent given the patient's recent history of living in a shelter. The history of present illness (HPI) indicates that the patient developed troublesome itching over the past week, which has been compounded by inadequate sleep. Furthermore, the absence of prior skin conditions, such as dermatitis or atopy, helps narrow the differential diagnosis primarily toward scabies. This history is critical, as it emphasizes the context in which the infestation likely arose—living in close quarters with others, where scabies can easily spread. The patient's past medical history reveals controlled essential hypertension but otherwise lacks notable chronic health issues. This lack of significant comorbid conditions may play a role in the patient’s immune response and susceptibility to skin infestations. Moreover, his consistent exercise regimen and healthy diet are encouraging positive health behaviors that may aid in recovery post-treatment. On examination, it was noted that the patient has scabietic burrows and vesicles in the internal folds of the elbows, legs, and thighs—all classic sites for scabies infestation. Accompanying excoriated papules were also documented, further substantiating the diagnosis. The patient's system review was largely unremarkable, indicating no systemic complaints or complications, which is promising as scabies typically does not induce systemic illness under normal circumstances. To confirm the diagnosis, the examination's findings are supported by literature indicating the distinctive present

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SOAP NOTE: SCABIES 1 SOAP Note: SCABIES 2 SCABIES Pat

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SOAP NOTE: SCABIES 1 SOAP Note: SCABIES 2 SCABIES Pat

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