Skin Comprehensive SOAP Note Template

Image Number 4 Selected

Patient Initials: ___H.P____              Age: _55______                                 Gender: Male_______

Subjective Data:

Chief Complaint (CC): I have swelling and redness on my left leg that is painful. It started suddenly yesterday and has been getting worse.

Skin Comprehensive SOAP Note Template

History of Present Illness (HPI): The patient is a middle-aged white individual with a documented history of diabetes mellitus that is well controlled with Metformin 500 mg PO BD. He arrives at the clinic with a history of swelling, redness, and pain in his left leg. He claims that a piece of metal at the construction site caused a little scratch on his left leg.

Later that evening, he observed a swelling at the scratch location, which was steadily developing and was accompanied by tenderness and redness. He claims that the swelling began in a small, localized area slightly anteriorly above the ankle joint and has subsequently spread circumferentially up to the mid-tibia. Since he first saw it, the redness and pain have worsened, and he gives it a severity rating of 5/10.

He says the afflicted region feels warm to the touch. He claims that the leg’s function has not been lost, as he can still ambulate and move it, but with pain. He hasn’t had any additional symptoms, such as a fever or chills. He has not taken any drugs or applied any topical lotions or ointments to the afflicted region. The patient has never experienced a problem like this before.

Medications: Metformin 500 mg PO BD

Allergies: No known food or drug allergies

Past Medical History (PMH): Diabetes mellitus, diagnosed five years ago

Past Surgical History (PSH):

  1. Herniotomy for an inguinoscrotal hernia 10 years ago
  2. Craniotomy to remove a subdural hematoma, 7 years ago

Sexual/Reproductive History: Heterosexual

Personal/Social History: He consumes at least four cans of beer in one sitting every weekend. He has never smoked cigarettes, but he did use marijuana in college and then stopped.

Health Maintenance:

He goes bicycle cycling every Saturday for a minimum of 30 minutes

Attends diabetes clinic once every month

He has a yearly appointment with his primary care provider for an annual checkup.

Immunization History:

Received two Covid-19 vaccine (Moderna), the first on January 4th 2021, and the second on February 10th, 2021

All the other vaccines were received during his childhood.

Significant Family History:

He is married to one wife and has four children, all of whom are living a healthy life

The father was diabetic and had prostate cancer. He died of diabetic ketoacidosis at 79 years of age in 2019

The mother had breast cancer and Covid-19. Died of Covid-19 at 82 years in 2020

Review of Systems:

General: Denies fever, chills, fatigue, or night sweats. Reports a recent weight gain from 174 lbs. to 178 lbs. in just three months

HEENT: Denies history of trauma or headaches. Eyes: No visual changes, eye pains, itchiness, redness, or diplopia Ears: Denies hearing loss or discharges. Nose:  Denies loss of smell, nasal discharge, bleeding, or itchiness Throat: Denies sore throat or voice changes

Respiratory: Denies cough, sputum, shortness of breath, chest pain, hemoptysis, or noisy breathing

Cardiovascular/Peripheral Vascular: denies chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication.

Gastrointestinal: denies nausea or vomiting, denies abdominal pain, no changes in bowel/bladder pattern

Genitourinary: denies change in urinary frequency, dysuria, or incontinence. He is heterosexual. Denies history of STDs or HPV.

Musculoskeletal: Denies arthralgia/myalgia, no history of arthritis or gout. Reports a history of trivial trauma inflicted by a piece of metal on the left leg. Denies limitation in his range of motion; however, he does move with discomfort.

Neurological: No episodes of syncope or dizziness, no headaches, no paresthesia. Denies memory loss; no twitches or abnormal movements; no history of gait disturbance or coordination problems. Denies history of seizures and falls.

Psychiatric: Denies psychotic episodes (delusional or hallucinatory experiences). Denies a history of anxiety or depression. No sleep disturbance, no history of mental illness. He denies suicidal/homicidal history.

Skin/hair/nails: Denies having any rashes or pigmentations on his skin. Swelling, erythema, tenderness, and warmth are reported on the skin of the left leg. Denies hair color changes or brittleness. There are no nail changes.

Objective Data:

Physical Exam:

Vital signs: B/P 119/82 mm Hg; Temperature 986 F; Weight: 178 lbs.; Height: 1.7m; BMI 27.94 kgm2

General: The patient is in a generally fair condition, oriented to time, place, and person, not in obvious respiratory illness, not pale, not jaundiced, not cyanosed, not edematous, and has no lymphadenopathies.

HEENT: PERRLA, EOMI, oronasopharynx airway is clear

Neck: Carotids with no bruit, no neck swelling

Chest/Lungs: On inspection, the chest rises bilaterally equally on inspiration, bilateral resonance on percussion, bilateral and equal air entry on auscultation

Heart/Peripheral Vascular: Normoactive precordium, S1, and S2 sounds heard, with no additional sound

Abdomen: On inspection, an inguinal incisional scar is present; abdominal distension is consistent with truncal obesity. No abdominal tenderness, swelling, or organomegaly on palpation. Bowel sounds are present on auscultation.

Genital/Rectal: Normal external genitalia. No lesions were suggestive of any pathology. The perineum is clean and has o pathological lesions.

Musculoskeletal: symmetric muscle development; Normal bulk, tone, and reflexes. Muscle strengths 5/5 in all groups.

Neurological: GCS 15/15. Oriented to time, place, and person.

Skin:

Case Study 4

Left leg (affected leg): The left leg appears to be swollen circumferentially from the ankle to the mid-tibia region. The circumferential swollen zone is 15 cm long and 33 cm in diameter, compared to the unaffected right leg, which is 29 cm in diameter at the same anatomic location. The affected area is erythematous, with a shiny surface and poorly demarcated flat borders.

There are no visible raised bumps, blisters, pus, or drainage from the affected area. The leg is edematous and warm to the touch, and the skin is tight, stretched, and indurated when palpated. When pressure or movement is applied to the swollen area or the entire leg, it becomes tender.

Diagnostic results:

  1. Compete, blood count,
  2. Blood culture
  3. Plasma glucose levels
  4. Hemoglobin A1C
  5. Urea, electrolytes, and creatinine levels

ASSESSMENT:

Differential Diagnoses

  1. Acute cellulitis
  2. Erysipelas
  3. Deep venous thrombosis
  4. Necrotizing fasciitis

Primary Diagnosis:

Acute cellulitis:

Rationale: Cellulitis is an infection that affects the skin and the underlying soft tissue, often caused by bacteria entering the body through a cut or other break in the skin. Symptoms of cellulitis include swelling, redness, tenderness, and warmth in the affected area. In this case, the patient is at risk for cellulitis due to a minor injury from a metal scratch and diabetes, which weakens his immune system and makes him more prone to infections.

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.