Skin Comprehensive SOAP Note Template (2 PDF

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tina jones soap note with details of first assessment...

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Week 4 Skin Comprehensive SOAP Note Template Patient Initials: __TJ_____

Age: __28_____

Gender: Female___

SUBJECTIVE DATA: Chief Complaint (CC): Patient states “I got a scrap on my foot a week ago that has progressively gotten worse”. “I am having a lot of pain and the wound now has drainage”. History of Present Illness (HPI): Miss Jones is a 28-year-old African American woman that presents today for a primary visit today with a complaint of a wound to the ball of right foot that is infected and painful. Miss Jones states that a week ago while walking on concrete steps outside, where she tripped, twisting her ankle, and scraping the ball of her foot. She went to the emergency room had xrays of her ankle and foot that were negative. Patient has had a temperature of 101.1 but has not taken any medication for fever. Patient reports throbbing pain and has been taking Tramadol 50mg PO three times daily with little relief. Tramadol was prescribed by the ER physician. Patient states there is swelling, redness, and drainage from wound for a few days. Patient has cleansed wound with peroxide and applying Neosporin twice a day.

S1 he is a 28-year-old obese African American female, awake, alert, and oriented to person place and thing. Miss Jones presents today for an initial primary care visit

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today complaining of an infected plantar foot wound x 1 week reporting symptoms of temperature 101.1F, denies taking anything for she is a 28-year-old obese African American female, awake, alert, and oriented to person place and thing. Miss Jones presents today for an initial primary care visit today complaining of an infected plantar

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foot wound x 1 week reporting symptoms of temperature 101.1F, denies taking anything for Medications: 1. Tramadol 50mg PO twice daily prn foot pain. 2. Ibuprofen 600 mg PO TID prn (menstrual cramps) 3. Albuterol inhaler 90 mcg 2 puffs every 4 hours prn wheezing 4. Proventil inhaler 90 mcg 2 puffs every 4 hours as needed for wheezing. 5. Metformin 500 mg PO twice daily (states she no longer takes this medication) 6. Tylenol 500 mg PO every 4 hours prn pain or fever. Allergies: 1. Penicillin- rash 2. Cat dander- Wheezing or difficulty breathing, itchy watery eyes. 3. Dust- wheezing. Past Medical History (PMH): 1. Asthma- was diagnosed at age 2 ½. Treating with the use of inhalers. Hospitalized as a child for exacerbation of asthma. 2. Type 2 diabetes – diagnosed at age 24. Patient denies monitoring her blood sugars. States she is non-compliant and has not taken Metformin for 3 years. 3. Painful Menstrual cycles that are irregular. Denies using birth control and is currently not sexually active. Last known menstrual cycle was three weeks ago. 4. Patient states she has noticed and increase in appetite and thirst for a few months. Past Surgical History (PSH): Patient states she has never had any surgeries. Sexual/Reproductive History: Heterosexual. Patient states irregular menstrual cycles and denies pregnancy. Patient states she is currently not sexually active therefore, she is not taking any birth control at this time. Personal/Social History: Patient states she lives with her mother and sister since her father passed away a year ago. She currently works 32 hours per week as she attends college part time. Denies smoking cigarettes. Occasionally drinks one or two alcohol drinks, maybe once or twice a week. Denies illicit drug use,

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but has used marijuana between the age of 15 to 21. Owns her own car, phone, and computer. She enjoys her job and is hoping to obtain a bachelor’s degree in accounting. She considers her mother her support system in life. She enjoys attending bible study with friends. She is active within her church and volunteers a lot. Health Maintenance: Last pap smear was 4 months prior. Denies regular breast exams and is not old enough for mammograms. States she does not follow a diabetic diet. Drinks soda and sweets regularly. Denies engaging in regular exercise. Immunization History: Up to date on childhood vaccinations. Tetanus injection one year ago. Denies having flu vaccine. Significant Family History: Mother: age 50, has hypertension, elevated cholesterol. Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes. Brother (Michael, 25): obesity. Sister (Britney, 14): asthma. Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol. Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol. Paternal grandmother: still living, age 82, hypertension. Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. Paternal uncle: alcoholism. Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems. Review of Systems: General: Upon exam patient is alert and oriented x 4. Vital signs are stable at this time except temperature 101.1. Appears well and in no distress at this time. Patient has a wound on right foot with signs and symptoms of pain and noted facial grimacing. HEENT: Patient’s skull is normocephalic, is atraumatic. States has headaches, blurred vision, and watering eyes when reading. Otherwise, PERRLA, light reflex is present, denies any hearing changes or ear pain. Denies throat pain or difficulty swallowing. No swelling of lymph nodes noted. Respiratory: Denies cough and no difficulty breath unless having asthma exacerbation. States when exposed to cat dander or dust will need inhaler due to wheezing. Cardiovascular/Peripheral Vascular: Denies any chest pain or cardiac issues except diagnosed with hypertension. Noted redness and slight edema of right bottom of foot but pulses are palpable in all extremities. Gastrointestinal: Denies abdominal pain, nausea, vomiting, hematemesis, constipation, diarrhea, hemorrhoids, dysphagia, odynophagia, food intolerance, early satiety, indigestion, heartburn, change in appetite, change in bowel pattern, rectal bleeding, melena, excessive flatulence or belching, liver or gallbladder problems, jaundice, history of hepatitis.

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Genitourinary: Denies dysuria, vaginal discharge, lesions, incontinence, problems with voiding, hematuria, frequency, suprapubic pain, nocturia, trouble initiating urinary stream, incomplete emptying, polyuria, stones, history of urinary tract infections, history of sexually transmitted infections, no vaginal pain, or swelling, sexual difficulties, hernias. Musculoskeletal: Denies any gait disturbance, slight weakness right foot due to wound, noted a recent injury to right foot with wound. Denies arthritis but does have pain in right foot when ambulating. Denies back pain, joint pain. States has some stiffness in the mornings. Slight limited range of motion in right foot. Neurological: Denies headaches, any numbness/tingling, visual changes, seizures, falls, syncope, local weakness, tremors, memory changes, muscle atrophy, vertigo, or dizziness. Psychiatric: Denies depression or anxiety, hallucinations, suicidal ideation, homicidal ideation, nightmares, nervousness, irritability, hypersomnia, insomnia, phobias. Patient states she did experience depression after her father passed away from a car accident. Skin/hair/nails: Patient states has redness and swelling of right bottom foot that started one week ago after injury. otherwise, no other skin changes. Denies skin lesions, petechiae, bruising, changed in moles, changes in hair. OBJECTIVE DATA: Physical Exam: Vital signs: weighs 90kg, BP 142/82, R.18 HR 86 temp 101.1, Blood sugar 238mg/dl. General: Upon exam patient is alert and oriented x 4. Vital signs are stable. Appears well and in no distress. Noted signs and symptoms of pain, with facial grimacing, bp is slightly elevated. HEENT: PERRLA. skull is normocephalic and is atraumatic. PERRLA, light reflex is present, nasopharynx is clear Neck: Neck is supple. Trachea is midline, no masses noted, jugular vein distention, bruit, or thyroid nodules noted at this time. Chest/Lungs: Lungs are clear to auscultation. Respirations are symmetrical and regular, unlabored, no wheezing, rhonchi, or rales. Heart/Peripheral Vascular: Upon auscultation rate is normal and heart tones are normal. No murmurs or clicks noted. Pulses are palpable in all extremities. Slight edema noted in right lower leg and foot. No edema noted in other extremities. Abdomen: Abdomen is soft to palpation. Non tender or distended. Bowel sounds positive in all quadrants. No hepatomegaly noted upon palpation. Genital/Rectal: No lesions or edema of genital area. No rectal edema or masses. Musculoskeletal: No abnormalities or deformities noted of all joints. Noted some pain in right lower leg and foot, and slight limited range of motion due to slight swelling and redness. Muscle strength in upper extremities is equal. No gout is noted.

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Neurological: Patient is alert and oriented x 4. Speech is clear and understood. Denies syncopal episodes or dizziness, no paresthesia, headaches. Denies change in memory or thoughts, no twitches, or abnormal movements. Denies history of gait disturbance or problems with coordination only slight weakness of right lower extremity due to wound. Denies falls or seizure history. Skin: Noted redness and swelling of right lower leg and foot. Denies rashes anywhere else on body, itching, or bruising. He denies history of skin cancer or lesion removal. Diagnostic results: 1. Acute pain of the right foot 2. Local infection of the skin and subcutaneous tissue of the foot. 3. Uncontrolled Diabetes Mellitus.

ASSESSMENT: Lab and Xray results: 1. Right ankle and foot x-ray- No fracture noted. Edema noted of tissue. 2. No labs were noted. Differential Diagnosis (DDx): 1. Acute pain of the right foot. 2. Local infection of the wound or skin and subcutaneous tissue of the foot. 3. Uncontrolled Diabetes Mellitus. PLAN: Obtain a wound culture during wound care and dressing change. Will obtain labs CBC and CMP today and for lab to call with any abnormal results. Continue Tramadol 50mg PO Tid. Will provide a new prescription to last patient until next visit. Will prescribe an antibiotic, Doxycycline 100mg PO 1 tab every 12 hours. This patient needs to be off work and elevate foot. Work excuse provided. Patient needs to follow up in three days to ensure that her wound is improving.

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