SOAP Note: Foot Pain

SUBJECTIVE:

Chief Complaint: The patient complains of foot pain.

History of present illness:

PMH:

The patient, TJ, has no past illnesses. She records having scrapped the bottom of her right foot while twisting her ankle while tripping. She also reports that they wound will not heal despite being constantly cleaned with soap, water and taking Tramadol 50MG.  Soap Note Foot Pain Essay Paper

Accidents/Injuries:

The patient tripped thereby scrapping the bottom of her right foot and twisting her ankle. When admitted to the emergency department, her x-rays showed no fractures. The patient is now taking Tramadol 50MG.

Hospitalizations:

TJ did not provide any account of recent hospitalizations.

FH:

The patient’s father had hypertension and type 2 diabetes. He is deceased after a car accident. Her mother was diagnosed with depression after the death of her spouse. She suffers from high cholesterol, and hypertension. The patient’s sister is also asthmatic while her only brother has no health concerns. Her (P) grandmother has high cholesterol. She is taking blood pressure medication for her hypertension. The patient’s (M) grandfather is deceased resulting from a car accident as well. Her uncle suffers from alcoholism. There is a family history of obesity as well.

Social History

The patient is single, and has no children. She is currently in college to obtain bachelors in accounting. She denies tobacco use and states that she last smoked marijuana at age 20 or 21. She is a social alcoholic taking alcoholic beverages 1-2 times/week

Allergies:

The patient is asthmatic. She is allergic to cats which cause her to wheeze. Her eyes also itch while she experiences asthma exacerbations. She is allergic to penicillin which gives her hives and rashes. TJ denies any allergies to latex and foods.

Current Medications:

The patient takes Tramadol 50MG, Advil 200MG, Prventil (Albuterol Sulfate) Inhaler 90MCG

Review of Systems:

General: TJ was then asked about her constitutional health, to which she states experiencing a 10 LB weight loss in the past month, but no fever, chills, or night sweats. TJ also, reports that the wound does not heal and that it displays redness, white purulent drainage and swelling. Her blood pressure is elevated and her blood sugar levels are uncontrolled.

Eyes: The patient has no eye pain, discharge or redness bust has blurry vision at times.

Head: She also reports no headaches or dizziness.

Ears: BF reports no change in hearing, no ear pain, and no ear drainage.

Nose: She has no epistaxis, and no congestion.

Mouth: She experiences no sore throat, and no difficulty swallowing.  Soap Note Foot Pain Essay Paper

ORDER  A PLAGIARISM-FREE PAPER HERE

Neck: She experiences stiffness when reading, and discoloration.

Chest: BF reports dyspnea, and wheezing.

Heart: She reports no chest pains, and no palpitations.

GI: She has no change in appetite, no abdominal pains, no bowel habit changes, and no emesis.

GU: BF reports no urinary urgency, no dysuria, and no change in nature of urine.

Gyn: The patient states she was experiencing no change in menses, no dysmenorrheal, no vaginal discharge, no pelvic pain and no amenorrhea/menopause.

Musculoskeletal: She reports ambulation difficulties r/t right foot wound. No muscle weakness, or bone issues.

Neurologic: BF experiences no weakness and no changes in sensation.

Psychiatric: She has no depressive symptoms, and no changes in sleep habits. Patient denies thought of hurting self or others.

Skin:  Patient reports acne skin breakouts.

Hematologic: heavy bleeding during menstrual cycle

Endocrine: uncontrolled diabetes type 2. Increased thirst and appetite.

OBJECTIVE:

Vitals: Blood pressure 113/78, O² sat 99%, pulse 91, respirations 18, temperature 36.0 C.

General: TJwas an edgy and flushed. She appeared a bit distressed and was smirking at times. Patient was obese. She experienced no distress during the assessment.

HEENT: Cardiovascular: S1, S2, no murmurs, gallops, or rubs. No S3 and S4.

Skin: Moist, mucous membranes, normal skin turgor, no tenting. No lower extremity edema.

Respiratory: Client’s breathing was quiet and unlabored. She could construct full sentences and her respiration was clear to auscultation.

Abdominal: 6 cm scar in RUQ and 10 cm scar at the midline in the suprapubic region. An abdominal assessment revealed no discoloration and bowel sounds were normoactive in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants. No masses noted in the LLQ; no organomegaly; no CVA tenderness; liver span 7 cm at MCL and no hernias.  Soap Note Foot Pain Essay Paper

Rectal: No hemorrhoids, fissures or ulceration; strong sphincter tone, fecal mass in the rectal vault.

Pelvic: no inflammation or irritation of the vulva, abnormal discharge, bleeding, masses or growth or tenderness upon palpation.

Urinalysis: Urine was clear, dark yellow with normal odor. No nitrites, WBCs, RBCs, or ketones detected; pH 6.5, SG 1.017

LABS:

No labs available to review at this time

TEST:

None to review at this time

Differential Diagnoses:

• Synergistic gangrene
• Vibrio vulnificus infection
• Aeromonas hydrophilia infection.

Name: Brandie S Culpepper

Section: NURS 6512C

Week 4                

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA:  TINA JONES IS A 28 YEAR-OLD A FEMALE WHO PRESENTS TO THE CLINIC WITH C/O RIGHT FOOT PAIN. SHE STATES SHE SCRAPED IT “A WHILE AGO” AND THOUGHT IT WOULD HEAL ON ITS OWN. SHE FURTHER STATES THAT “IT’S LOOKING PRETTY NASTY” WITH REDNESS, SWELLING, AND PRULENT DRAINGAGE PRESENT. VOICES C/O PAIN “7” (SCALE 0-10) TO RIGHT FOOT AND VOICES THAT PAIN WORSENS WITH WEIGHT BEARING ACTIVITIES AND WALKING.  SHE HAS BEEN CLEANING RIGHT FOOT WOUND WITH SOAP AND WATER AND APPLYING NEOSPORIN.

Chief Complaint (CC): INCREASED RIGHT FOOT PAIN R/T UNHEALED FOOT WOUND WITH REDNESS, SWELLING, AND PRULENT DRAINAGE NOTED.

History of Present Illness (HPI): MS. JONES STATES THAT SHE SCRAPED THE BOTTOM OF HER RIGHT FOOT AND TWISTED HER ANKLE AFTER TRIPPING WHILE GOING DOWN BACK STEPS.  AN X-RAY WAS PERFORMED 3 DAYS AGO IN THE ED, NO FRACTURES NOTED. PATIENT HAS BEEN TAKING TRAMADOL 50MG BID AND KEEPING FOOT WOUND CLEAN WITH SOAP AND WATER. SHE CAME IN TODAY WITH C/O INCREASED PAIN, SWELLING, REDNESS, WARMTH, AND PRESCENCES OF PRULENT DRAINAGE. SHE STATES THAT IT HAS BECOME MORE CHALLENGING TO WALK ON RHIGHT FOOT, STATES SHE FEELS A SHOOTING PAIN WHEN WALKING. SHE RATES HER PAIN 7/10 BUT BECOMES MORE SEVERE WITH WEIGHT-BEARING ACTIVITIES. MS. JONES CONTINUES TO STATE THAT SHE HAS BEEN HAVING SOME INCREASE IN URINATION, THIRST, AND APPETITE. HOWEVER, SHE REPORTS THAT SHE HAS HAD AN 10LB WEIGHT LOSS WITHOUT TRYING.  Soap Note Foot Pain Essay Paper

Medications:

1. TRAMADOL 50MG: 2 TABS TID (MORNING, NOON, AND NIGHT). LAST DOSE TAKEN THIS MORNING BEFORE COMING IN.
2. PRVENTIL (ALBUTEROL SULFATE) INHALER 90MCG: 2 PUFFS. NEEDS 2-3 TIMES/WEEK AND HAS BEEN NEEDING UP TO 3 PUFFS LATELY. LAST DATE TAKEN UNKNOWN.
3. ADVIL 200MG: 3 TABS TID OCCASIONALLY FOR CRAMPS. LAST TAKEN THREE WEEKS AGO.
4. DENIES VITAMINS OR SUPPLEMENT USE.

Allergies:

1. CATS: SNEEZING, ITCHY EYES, WHEEZING, ASTHMA EXACERBATION.
2. PENICILLIN: RASH AND HIVES
3. DENIES FOOD ALLERGIES
4. DENIES LATEX ALLERGY

Past Medical History (PMH):

1. ASTHMA, WELL CONTROLLED: TRIGGERS ARE MOSTLY CATS. ALSO, DUST AND RUNNING UP STEPS. ASTHMA ATTACKS WITH FEELINGS OF CHEST AND THROAT TIGHTNESS, WHEEZING, AND FEELINGS OF “NOT ENOUGH AIR”. LAST ASTHMA ATTACK WAS IN HIGH SCHOOL.

2. DIABETES MELLITUS TYPE 2, POORLY CONTROLLED. DIAGNOSED AT AGE 24.

ORDER   HERE

3. LAST HOSPITALIZED AT AGE 16 D/T ASTHMA ATTACK.

Past Surgical History (PSH): VOICES NO PAST SURGICAL HISTORY

Sexual/Reproductive History:

1. JONES HAS IRREGULAR MENSTRUAL PERIODS THAT ARE HEAVY AND PAINFUL. SHE STATES THEY LAST FOR 7 DAYS. VOICES FIRST TWO DAYS ARE VERY PAINFUL AND TAKES ADVIL 200MG 3 TABS TID TO RELIEVE PAIN DURING THIS TIME. VOICES SHE IS NOT CURRENTLY SEXUALLY ACTIVE.

Personal/Social History:

1. SINGLE, NO CHILDREN

2. RESIDES WITH MOTHER

3. CURRENTLY IN COLLEGE TO OBTAIN BACHELOR’S IN ACCOUNTING.

4. BAPTIST, INVOLVED WITH FAMILY CHURCH.

5. DENIES TOBACCO USE.

6. LAST SMOKED MARIJUANA AT AGE 20 OR 21.

7. SOCIAL ALCOHOLIC BEVERAGES 1-2 TIMES/WEEK

8. COPED APPROPRIATELY AFTER FATHER’S DEATH.

Immunization History: IMMUNIZATIONS ARE UP TO DATE. TETANUS VACCINATION RECEIVED IN THE LAST YEAR. DENIES RECEIVING THE INFLUENZA VACCINATION.

Health Maintenance:

1. LAST BLOOD SUGAR CHECK UNKNOWN. STATES, “ABOUT A MONTH AGO.” CURRENT BLOOD SUGAR 238.

2. INSUFFICIENT BLOOD GLUCOSE MONITORING.

3. METFORMIN LAST TAKEN 3 YEARS AGO AFTER TAKING FOR A YEAR. DOSE UNKNOWN.

4. DIAGNOSED WITH DIABETES TYPE 2 3 YEARS AGO.

5. EATS 3 MEALS A DAY.

6. IMMUNIZATIONS ARE UP TO DATE.

7. TETANUS VACCINATION RECEIVED IN THE LAST YEAR.

8. DENIES RECEIVING THE INFLUENZA VACCINATION.

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

1. FATHER: DIABETES TYPE 2 AND HTN. DIED IN CAR ACCIDENT LAST YEAR IN A CAR ACCIDENT.

2. MOTHER: HTN, HIGH CHOLESTEROL. MOTHER EXPERIENCE DEPRESSION AFTER SPOUSE DIED.

3. 1 SISTER WITH CONTROLLED ASTHMA

4. 1 BROTHER WITHOUT ANY HEALTH CONCERNS.

5. (P) GRANDMOTHER: HIGH CHOLEROL. TAKING BP MEDS FOR HTN.

6. (P) GRANDFATHER: TYPE 2 DIABETES, HTN. DIED OF COLON CANCER.

7. (M) GRANDMOTHER: DIED 5 YEARS AGO, POST CVA. HIGH CHOLESTEROL AND HTN.

8. (M) GRANDFATHER: HTN, MI. DIED IN CAR ACCIDENT WHEN PATIENT WAS A CHILD.

9. (P) UNCLE: ALCOHOLISM

10. FAMILY HISTORY OF OBESITY.

Review of Systems

General: UNCONTROLLED PAIN MANAGEMENT AND AMBULATION DIFFICULTIES R/T RIGHT FOOT WOUND. SUSPECTED NONE HEALING DIABETIC FOOT WOUND TO RIGHT FOOT WITH REDNESS, SWELLING, AND WHITE PURULENT DRAINAGE NOTED. ELEVATED BLOOD PRESSURE AND NONE CONTROLLED BLOOD SUGAR LEVELS. UNINTENTIONAL 10 LB WEIGHT LOST IN THE PAST MONTH.

HEENT: BLURRY VISION AT TIMES. NO EAR PAIN OR HEARING DIFFICULTIES. NO SORE THROAT, NASAL ISSUES, CHANGES IN VOICE, OR DIFFICULTY SWALLOWING. NO LOSS OF TASTE AND SMELL. SHE VOICES NO USE OF GLASSES OR CONTACTS.

Neck: DISCOLORATION AROUND NECK. SOME STIFFNESS WHEN READING

Breasts: NO LUMPS, PAIN OR TENDERNESS.

Respiratory: NO SHORTNESS OF BREATH, WHEEZING, COUGHING, OR DIFFICULTY BREATHING

Cardiovascular/Peripheral Vascular: DENIES CHEST PAIN, SHORTNESS OF BREATH, AND HEART PALPITATIONS. DENIES NUMBNESS AND TINGLING TO THE LOWER EXTREMITIES.

Gastrointestinal: NO CHANGE IN BOWEL HABBITS. NO DIGESTIVE ISSUES, NO ABDOMINAL DISCOMFORT.

Genitourinary: FREQUENT URINATION. NO PAIN WHEN VOIDING, NO CURRENT UTI.

Musculoskeletal: AMBULATION DIFFICULTIES R/T RIGHT FOOT WOUND. NO MUSCLE WEAKNESS, OR BONE ISSUES.

Psychiatric: NO DEPRESSION OR SUICIDE IDEATION.

Neurological: OCCASIONAL HEADACHES. NO CONFUSION, SEIZURE ACTIVITY, OR STROKE. NO MEMORY OR MOOD CHANGES.

Skin: ACNE BREAK-OUTS. DARK DISCOLORATION AROUND NECK. No BRUISING.

Hematologic: HEAVY BLEEDING DURING MENSTRUAL CYCLE

Endocrine: UNCONTROLLED DIABETES TYPE 2. INCREASED THIRST AND APPETITE.

Soap Note Foot Pain Essay Paper