Clinica notesss - soap PDF

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CC: “ I have a cut to my right hand and is very swollen” History of Present Illness: Patient states that she sustained an injury or cut in her right hand after trying to reach under a cabinet for a mouse trap and caught her hand on a piece of broken glass. The incident occurred two days ago but she states that did not seek medical attention and now is swollen and she has pain. Patent did not take anything to relieve pain. Medical history: Anxiety, HTN, arthritis Surgical history: hysterectomy, appendectomy Family history: Father: HTN, Mother: colon CA Social History: Denies tobacco use, substance abuse, or alcohol use. Review of Systems: General: Denied fever, chills, fatigue, or night sweats. Chest/Respiratory: Denies cough or wheezing. Cardiovascular: Patient denies chest pain, palpitations, or syncope. Gastrointestinal/Abdomen: Denies abdominal discomfort. Integumentary: Laceration to right hand, bleeding heavily. Musculoskeletal: Right hand pain and swelling to posterior hand near second knuckle, tender to touch and with movement. Neurological: Alert and oriented x4. Denies numbness or tingling to extremities. Current Medications: lovastatin 20 mg nightly, ASA 325 mg daily, gabapentin 100 mg TID, fish oil 300 mg daily, fluoxetine 20 mg daily, losartan 100 mg daily, vitamin D 1000 units daily Allergies: sulfa Objective Physical Exam Vital Signs: T 98.3, P 67, R 16, BP 158/82, General: Alert, appears stated age with appropriate affect. Appears well-nourished. Head: Normal hair distribution, normocephalic. Resp: Respirations WNL, symmetrical. Chest expansion equal bilaterally. Diminished lung sounds in all fields at this time. No wheezes, stridor, crackles, or pleural rubs. CV: Regular rate and rhythm, no murmur, gallops, or rubs. 2+ pulses in all extremities. GI: Rounded and soft without guarding or tenderness with palpation. No rebound tenderness or masses noted. Active bowel sounds present in all quadrants. Integument: Normal turgor, warm, and dry. 3 cm bleeding laceration noted to right posterior hand. Musculoskeletal: Pain with movement of right hand. Neurological: Oriented age-appropriate. Motor functions intact. Primary Diagnoses

1. Laceration Assessment: Plan: 1. XR right hand to rule out fracture/tendon involvement with result: soft tissue injury with no acute osseous abnormality 2. Repair laceration: cleanse lac with saline and betadine, 8 sutures applied in sterile fashion, well approximated. Bacitracin applied to lac and covered with dry dressing/ACE wrap. 3. Tdap administration 4. Meds: cephalexin (Keflex) 500 mg 1 capsule QID x 7 days 5. Ibuprofen 800 mg q6 hrs as needed for pain...