Pediatric Case Study: Toddler with a rash and tugging at his ear

Read the Pediatric Case Study and follow the instructions below:
Complete a focused SOAP note on this pediatric patient. (You will uncover more subjective data through your history taking, so be creative. You will also decide what your objective findings on physical exam will be.)
Pediatric Case Study: Toddler with a rash and tugging at his ear
Sam is a 16 month old who presents to your office with a history of low grade fever for 24 hours, runny nose for a week, tugging at his left ear for two days and not eating much. He has a rash that comes and goes since birth, but is worse in the winter and when mom changes to Tide with Bleach laundry detergent. He is crying off and on and wanting to be held more than usual. Sam had one diarrhea stool, today, but has had normal urine output. History of one ear infection at 8 months of age, responded to first line antibiotics, Amoxicillin. So far she has tried giving him cetirizine and ibuprofen and is putting Vick’s Vapo Rub on the soles of his feet.
Sam’s mom describes that his rash comes and goes since shortly after his birth, but is worse in the winter and when she changes to Tide with Bleach laundry detergent. It started as rosy cheeks, and sometimes is on the inside of his elbows, behind his knees and on the outside of his upper arms and thighs. Nothing really helps it go away.
The soap note should include review of system and physical assessment. Please include at least 4 references