Episodic/Focused SOAP Note Template SAMPLE Paper

Episodic/Focused SOAP Note Template SAMPLE Paper

Episodic/Focused SOAP Note Template SAMPLE Paper

Episodic/Focused SOAP Note Template

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Patient Information:

Initials: P.F, Age: 16 years, Sex: Male, Race: White

S.

CC (chief complaint): Right foot pain.

HPI: A 16-year-old White male presented with his mother with complaints of right foot pain. The patient reports swelling and the presence of puss and discharge on the right foot. He rates the foot pain at 8/10 pain. The patient was seen in ED last week and given Keflex PO. He was also seen by the podiatrist last Thursday who removed an ingrown toe nail.

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Current Medications: PO Keflex.  Tylenol 500 mg PRN for foot pain

Allergies: No drug or food allergies.

PMHx:  No history of chronic illnesses. Immunization is current.

Soc& Substance Hx: The patient is in 11th grade 11. He lives with his both parents and two younger siblings 13 and 7 years. His hobbies are playing baseball and painting. He is the Captain of his school’s baseball team. He denies a history of alcohol use, smoking, or use of illicit drugs. He reports having many friends at school and in their neighborhood. The mother states that the boy has had a tremendous academic performance.

Fam Hx: The great-grandmother had Alzheimer’s and died at 95 years. The paternal grandmother has HTN and a history of MI. The maternal aunt has cervical cancer. The parent and siblings are alive and well.

Surgical Hx: No history of surgery.

Mental Hx: No history of mental illnesses.

Violence Hx: No history of abuse or bullying.

Reproductive Hx: No sexual concerns.

ROS:

GENERAL: Reports mild HOB. Denies weight changes, chills, body weakness, or fatigue.

HEENT: Denies visual changes, blurred/double vision, hearing loss, tinnitus, sneezing, congestion, runny nose, or sore throat.

SKIN: Reddening of the skin on the right toe. Denies bruises, rash, or itching.

CARDIOVASCULAR: Denies chest pain/pressure, palpitations, SOB, or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting, abdominal pain, constipation, or diarrhea.

GENITOURINARY: Denies penile or urinary symptoms.

NEUROLOGICAL: Denies headache, dizziness, paralysis, or tingling in the extremities.

MUSCULOSKELETAL: Denies muscle or back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Negative for enlarged nodes.

PSYCHIATRIC: Denies a history of depression or anxiety.

ENDOCRINOLOGIC: Denies excessive sweating, cold or heat intolerance, polyuria, or polydipsia.

REPRODUCTIVE: No reports of urinary or penile discharge. Not sexually active.

ALLERGIES: Denies history of asthma, hives, or eczema.

O.

Physical exam:

Vital signs: Temp-99.886 F; BP-120/74; Resp-16; HR-86

            Height- 5’5; Weight- 135lb.; BMI-23.3

Cardiovascular: No edema or jugular vein distension noted. On auscultation S1 and S2 are present and loud. No heart murmurs, S gallop, or friction rubs are present. Femoral and abdominal bruits are absent.

Respiratory: No thoracic cavity deformities observed. Chest rises and falls in unison during inspiration and expiration. On percussion, the lungs are resonant. Normal Broncho-vesicular sounds on auscultation.

Skin: Skin is fair, warm, and dry. The skin on the right toe is red, hot, and tender to touch. Right, hallux has swelling, puss, and discharge. No necrosis was noted. No generalized skin rash, lesions, or moles.

Diagnostic results: CBC, BMP, A1C, Lipid panel- Awaits results

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).

Cellulitis of right toe (L03.031): Cellulitis is a non-necrotizing inflammation of the skin and subcutaneous tissue from a primary infection. The four cardinal symptoms of cellulitis are pain, swelling, warmth, and erythema (Ong et al., 2022). This is the primary diagnosis based on positive findings of swelling, hot and tender to touch, and erythematous appearance of the right toe as well as low-grade fever.

Ingrown Toenail (L60.0): This is an incurvation or impingement of a nail border into its adjacent nail fold, resulting in pain (Kim et al., 2021).  Pain occurs at the corner of the nail fold. The patient had an ingrown toenail that was removed by the podiatrist. However, this was not the primary cause of pain and discharge.

Necrotizing fasciitis (M72. 6): The cardinal symptoms of necrotizing fasciitis are pain and tenderness on the skin of the underlying muscle. The pain precedes erythema, fever, muscle pain, and generalized body weakness (Chen et al., 2020). The patient has positive symptoms of foot pain, tenderness, erythema, and low-grade fever. However, there is no necrosis of the subcutaneous tissue, ruling out Necrotizing fasciitis as the primary diagnosis.

. P

  1. Cellulitis

Diagnostics:  Culture of needle aspiration within 6 hours, to identify the colonizing bacteria (Sullivan & de Barra, 2018).

Therapeutic interventions: Ceftriaxone 1g IM; Continue taking Keflex PO (Sullivan & de Barra, 2018).

Education: The patient was advised if symptoms do not improve or worsen in the next 48-72 hours to call the office and in the event of an emergency go to the ED.

Follow-up: Scheduled follow-up in the outpatient clinic after 2 weeks to monitor progress and assess complications.

  1. Ingrown Toenail

Diagnostic: Order for Right hallux X-ray to rule out osteomyelitis (Kim et al., 2021).

 

Therapeutic interventions: Nail excision and destruction of the adjacent nail matrix. Continue taking Keflex PO.

Education: Wear less constricting shoes and trim the nail straight across (Kim et al., 2021).

Soak the toe in warm water 2 or 3 times a day, redress it, and avoid harsh chemicals.

Follow-up: Scheduled follow-up in the outpatient clinic after 2 weeks to monitor progress and assess complications.

  1. Necrotizing fasciitis

Diagnostics: Blood and wound cultures

Therapeutic interventions: Surgical debridement; IV Vancomycin 1 gm BD plus IV Ceftriaxone 1 gm BD (Zhang et al., 2022).

Education: Infection prevention measures.

Follow-up: Scheduled follow-up in the outpatient clinic after 2 weeks to monitor progress and assess complications.

Reflection: I agree with the preceptor’s diagnosis of cellulitis and the treatment plan. I learned that cellulitis occurs following an invasion of the skin or invasion by certain bacteria including Staphylococcus aureus, Streptococcus pneumonia, and Vibrio vulnificus. It is broadly categorized into non-purulent and purulent cellulitis with the latter having pus in the affected part. In a different situation, I would order a Culture of needle aspiration within 6 hours, to identify the colonizing bacteria and guide the treatment plan (Sullivan & de Barra, 2018). Health promotion and disease prevention for this patient should focus on maintaining the cleanliness of the right toe to avoid secondary infection and adherence to antibiotic therapy.

References

Chen, L. L., Fasolka, B., & Treacy, C. (2020). Necrotizing fasciitis: A comprehensive review. Nursing, 50(9), 34–40. https://doi.org/10.1097/01.NURSE.0000694752.85118.62

Kim, J., Lee, S., Lee, J. S., Won, S. H., Chun, D. I., Yi, Y., & Cho, J. (2021). A minimally-invasive, simple, rapid, and effective surgical technique for the treatment of ingrown toenails: a reminder of the original Winograd procedure. International Journal of Environmental Research and Public Health, 18(1), 278. https://doi.org/10.3390/ijerph18010278

Ong, B. S., Dotel, R., & Ngian, V. J. J. (2022). Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis? International Journal of general medicine, 15, 6561–6572. https://doi.org/10.2147/IJGM.S326459

Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical medicine (London, England), 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160

Zhang, L. X., Liang, Z. J., Zhao, B. Y., Shi, X. W., Zhang, T., Liu, H., & Yu, X. H. (2022). Delayed diagnosis and management of necrotizing fasciitis of the left lower leg: A case report. Medicine, 101(43), e31231. https://doi.org/10.1097/MD.0000000000031231

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Case Study:

16 year-old male presents with mom to establish and complains of R foot pain. R hallux has swelling, puss, discharge, and 8/10 pain for the past year. Was seen in ED last week and given Keflex PO and saw podiatrist last thursday who removed the toe nail.

ICD 10 Codes/CPT Codes: L03.031

(Cellulitis of right toe) F33.2

(Ingrowing nail) H61.23

Treatment Plan:

– Labs completed in the office today will call with results. CBC, BMP, A1C, Lipid panel

Notes: Call the office if symptoms do not improve or worsen. Call 911 anytime you think you may need emergency care.

– Continue taking ABT from ED visit, administered Ceftriaxone IM. Patient was advised if symptoms do not improve or worsen in the next 48-72 hours to call the office and in the event of an emergency go to the ER.

– Order for R hallux Xray to rule out osteomyelitis – New order for podiatry consult.

Assignment

Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

You can make up pt past medical history, social history, medication list, etc.

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