Case:
Ms. N is a 23-year-old woman who comes to see you complaining of a rash.

Ms. N complains of frequent “breakouts” on her face for the last several years. She reports the use of many topical over-the-counter agents over the years. She complains of feeling greasy and the need to “squeeze pus” out of lesions on a regular basis.

On examination, over the forehead, cheeks, and chin there are many erythematous papules, occasional pustules, and open and closed comedones. There is a predominance of larger nodules along the jaw line. Similar erythematous papules involve the upper back and chest. There is neither significant background erythema nor scaling in the scalp, eyebrows, or nasolabial folds.

The patient is in good health and is not overweight. She is not taking any oral medications. She reports regular menstrual cycles and notes that the breakouts are worse around the time of her period. She does not report easy flushing or any increased hair growth on the face or chest. She has 1 healthy child.

A management plan was discussed with the patient, including an appropriate skin care regimen, appropriate product selection, and use of systemic and topical medications. At follow-up in 3 months, the patient had significantly fewer active lesions with evidence of dyspigmentation associated with resolving lesions.

SOAP NOTE:
S: 23-year-old woman complains of a frequent breakouts/rash for the last few years. She reports that her breakouts get worse around the time of her menstrual period. Additionally, she states that her skin is increasingly greasy, and she often squeezes the pus out of the lesions. Over the years she has used many over-the-counter products on her skin. Patient is in good health, has no significant medical history, and is not taking any oral medication.

O: Skin: Erythematous papules, occasional pustules, and open and closed comedones are evident on patient’s forehead, cheeks, chin, upper back, and chest. Larger nodules observed along jaw line. There is no erythema or scaling on scalp, eyebrows or nasolabial folds.

A: Folliculopapular eruption that predominantly affects the face, chest, and upper back.

PCOS

P: Patient was advised of a proper skin care regimen. Including the use of topical and systemic medications. Further testing to rule out PCOS. Follow up was arranged for three months.

Summary:
Polycystic Ovarian Syndrome is a hormonal disorder most commonly found in women of reproductive age. For these women, their eggs often don’t get released from the ovary on a regular basis. Symptoms generally begin around the time of puberty. They can include irregular periods, increased androgen levels, and polycystic ovaries. The increased androgens can cause hirsutism as well as severe acne. Polycystic ovaries are often larger than healthy ovaries, and contain fluid around the eggs, this can cause them to function irregularly. Symptoms are exacerbated by obesity or increased weight gain. Although the exact cause of PCOS is unknown, it can be affected by increased insulin, low grade inflammation, heredity, and excess androgen. PCOS can cause the patient to experience problems with fertility, miscarriage or premature birth, gestational diabetes, nonalcoholic steatohepatitis, metabolic syndrome, type 2 diabetes, sleep apnea, depression, anxiety and eating disorders, abnormal uterine bleeding or endometrial cancer.

Reflection:

Posted on this page is my first stab at writing a SOAP note. At the time, the concept of a SOAP note was an unfamiliar one, and my first attempt at it, proved to be a great learning experience. When faced with the task, my first thought was “where do I begin?” Having all the information about the case at the time of the assignment, allowed my venture into this new form of documentation to go as smoothly as possible. I approached the task by first thoroughly reading the information presented about the case. My next step was to familiarize myself with the format and purpose of a SAOP note. Once I felt that I knew enough about it to try to create one on my own, I began to sort the relevant information into their prospective categories. Lastly, I adjusted the formatting to fit that of a typical SAOP note. I found the assessment and plan portions of the document to be most challenging. Although the information was all there, due to my lack of clinical knowledge and experience, those sections felt more forced than the others. Overall, I believe that my skills as writing a SOAP note can use some work, and that it will improve upon increased experience in both documenting information in this manner, as well as clinical medicine.

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