What should a SOAP note include for a patient presenting with a rash?

SOAP Note Structure for a Patient Presenting with Rash

A SOAP note for a rash must systematically document the morphology, distribution, timing, and associated symptoms to differentiate benign conditions from life-threatening diagnoses, while capturing medication history and impact on daily function.

Subjective Component

Document the following specific elements:

• Onset and progression: Record the exact date when the rash first appeared and document how it has evolved since onset 1, 2
• Morphologic description from patient: Ask the patient to describe what the rash looks like (bumps, blisters, flat spots, purple marks) 2
• Distribution pattern: Where did it start, and has it spread? Does it involve skin creases, face and chest, or mucosal surfaces (eyes, mouth, genitals)? 1, 3
• Associated symptoms:
  • Prodromal illness (fever, malaise, upper respiratory symptoms) 1
  • Skin pain or tenderness 1
  • Pruritus (itching) and its severity 3
  • Respiratory symptoms (cough, dyspnea, bronchial hypersecretion) 1
  • Gastrointestinal symptoms (diarrhea, abdominal distension) 1
• Medication history: All medications taken in the previous 2 months, including over-the-counter and complementary therapies, with exact start dates and any recent dose changes or brand switches 1
• Exposure history:
  • Recent travel history 1
  • Exposure to individuals with specific infections (tuberculosis, pertussis, measles, varicella) 1
  • Occupational or recreational chemical exposures 3
  • Contact with soaps, detergents, cosmetics, jewelry, or new personal care products 3, 4
• Atopic history: Personal and family history of childhood eczema, asthma, hay fever, or atopic disease in first-degree relatives 3
• Previous drug allergies: Document type and details of any prior reactions 1
• Impact on quality of life: Sleep disturbance, effect on work or school, and patient expectations 3

Objective Component

Perform and document these specific physical examination findings:

• Vital signs: Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation 1
• Baseline body weight 1
• Morphologic classification: Categorize the rash as petechial/purpuric, erythematous, maculopapular, or vesiculobullous 2
• Body surface area (BSA) involved: Estimate percentage of skin affected 1
• Specific lesion characteristics:
  • Look for target lesions (particularly atypical targets), purpuric macules, blisters, and areas of epidermal detachment 1
  • Assess for blister formation 1
  • Document presence of crusting, weeping, or grouped vesicles suggesting infection 3
• Distribution pattern: Document exact anatomic locations and whether symmetric or asymmetric 3, 2
• Mucosal examination: Examine all mucosal sites (oral mucosa, eyes, nose, genitalia) for mucositis, blisters, and erosions 1
• Signs of systemic illness: Assess for fever and other systemic signs 2
• Consider serial clinical photography for monitoring 1

Assessment Component

Formulate your clinical impression:

• Primary diagnosis or differential diagnoses: Based on morphology, distribution, and clinical features 2, 5
• Severity grading: Use standardized grading systems when applicable (e.g., Grade 1-4 for immune-related adverse events based on BSA and symptoms) 1
• Rule out life-threatening conditions: Explicitly state whether you have considered and ruled out dangerous rashes such as Stevens-Johnson syndrome/toxic epidermal necrolysis, meningococcemia, or severe drug reactions 1, 2
• Identify potential causative agents: Document suspected culprit drugs or exposures 1
• Note any complications: Secondary infection, respiratory involvement, or other organ system involvement 1, 3

Plan Component

Structure your management approach:

• Immediate interventions:
  • Discontinue any suspected culprit medications immediately 1
  • For severe cases (Grade 3-4), document need for hospitalization or urgent specialist consultation 1
• Topical therapy:
  • Replace all soaps with dispersible cream cleansers 3, 6
  • Prescribe emollients liberally (apply twice daily, 30-60g per application for arms, prescribe 400-500g containers) 7, 3
  • For inflammation, prescribe topical corticosteroids: hydrocortisone for mild cases (apply not more than 3-4 times daily in adults and children over 2 years) 4, or higher potency agents (betamethasone valerate 0.1% or mometasone 0.1% once daily) for moderate-to-severe cases 7, 6
• Systemic therapy (if indicated):
  • For Grade 2-3 rash: Prednisone 0.5-1 mg/kg, tapering over 4 weeks 1
  • For Grade 4 rash: IV methylprednisolone 1-2 mg/kg with slow taper 1
• Adjunctive measures:
  • Oral antihistamines for pruritus 1
  • Consider sedating antihistamines at night for sleep disturbance 3
  • For severe pruritus without rash, consider gabapentin, pregabalin, aprepitant, or dupilumab 1
• Infection management:
  • Obtain bacterial cultures if crusting or weeping present; prescribe flucloxacillin for suspected Staphylococcus aureus 3
  • Initiate systemic acyclovir if grouped vesicles suggest herpes simplex 3
• Patient education:
  • Demonstrate proper application technique for emollients and medications 3, 6
  • Provide written instructions on application frequency, quantity, and technique 3, 6
  • Advise on environmental modifications (lukewarm water, cotton clothing, avoid harsh detergents) 3
  • Keep fingernails short to minimize scratching damage 3, 6
• Follow-up and monitoring:
  • Schedule dermatology consultation if autoimmune skin disease suspected or if no improvement within 2-4 weeks 1, 7
  • For drug reactions, provide written information about drugs to avoid and encourage MedicAlert bracelet 1
  • Document drug allergy in patient's chart and report to pharmacovigilance authorities 1
  • Arrange follow-up within specified timeframe based on severity 1
• Diagnostic testing (if needed):
  • Consider skin biopsy if diagnosis uncertain 1
  • Recent complete blood count and comprehensive metabolic panel 1
  • Consider patch testing if contact dermatitis suspected and standard management fails 3

Critical Pitfalls to Avoid

• Failing to ask about recent medications: Drug reactions are a leading cause of serious rashes, and the 2-month medication history is essential 1
• Underprescribing emollients: Prescribe adequate quantities (400-500g containers) as underprescribing leads to treatment failure 7
• Missing mucosal involvement: Always examine all mucosal surfaces, as involvement suggests more severe conditions like Stevens-Johnson syndrome 1
• Delaying discontinuation of suspected drugs: If drug reaction is suspected, stop the medication immediately 1
• Steroid phobia leading to undertreatment: Address patient concerns about corticosteroids, as undertreatment is common and problematic 6