Soap Notes
J.L. SOAP NOTE
Subjective
J.L. is a 63-year-old white female who presented to the ER with right lower extremity pain and swelling with subsequent changes to the skin, including formation of bullous ulcers. She had blistering over the past four days that started to enlarge. The doctor prescribed her Bactrim. Erythema, swelling, and pain progressively got worse. She denies any fever or chills. PMH:
COPD, Hypertension, Diabetes mellitus, Osteoporosis, Fibromyalgia, Osteoarthritis, Morbid obesity Allergies: Morphine Nubain
Social History: Patient denies smoking and alcohol use. She is disabled and lives at home with her husband.
Objective
Medications: Clonazepam 0.5 mg by mouth once daily Simvastatin 10 mg by mouth at bedtime Singulair 10 mg by mouth once daily Zanaflex 4 mg by mouth every 12 hours Lovaza 1 gram by mouth two times daily Thermazene Topical Cream one application two times daily Nyamyc one application two times daily Sucralafate 10 mL by mouth before meals and at bedtime Bactroban Ointment one application two times daily for 7 days Omeprazole 20 mg by mouth before breakfast Physical Exam: 216 lbs 5’4” BMI 37.5 kg/m2
HEENT: Oropharynx is somewhat dry and with significant erythema.
Extremities: Adequate pulses, but there is lower extremity edema bilaterally. Patient has open wound on right foot, leg with erythema that goes up to the thigh, also has yeast infection in the buttock area. Skin: Patient has yeast infection described as erythema and satellite lesions in the inguinal and under abdominal fold area.
Vital signs: Temp 97.9 BP 124/70 P 103 RR 16
Labs:
Na 120 mmol/l K 5.5 mmol/l Cl 93 mmol/l CO2 26 mmol/l BG 91 mg/dl BUN 83 mg/dl Cr 3.3 mg/dl CrCl 26.99 ml/min Ca 7.7 mg/dl Total Protein 4.9 g/dl Alb 2.5 g/dl Corrected Ca 9.22 mg/dl Anion Gap 11 mmol/L WBC 14.1 th/ul RBC 3.12 mil/ul Hgb 9.5 g/dl Hct 27.5% MCV 80 fl MCH 28.2 pg MCHC 31.8 g/dl Plt 386 th/ul
Subjective
J.L. is a 63-year-old white female who presented to the ER with right lower extremity pain and swelling with subsequent changes to the skin, including formation of bullous ulcers. She had blistering over the past four days that started to enlarge. The doctor prescribed her Bactrim. Erythema, swelling, and pain progressively got worse. She denies any fever or chills. PMH:
COPD, Hypertension, Diabetes mellitus, Osteoporosis, Fibromyalgia, Osteoarthritis, Morbid obesity Allergies: Morphine Nubain
Social History: Patient denies smoking and alcohol use. She is disabled and lives at home with her husband.
Objective
Medications: Clonazepam 0.5 mg by mouth once daily Simvastatin 10 mg by mouth at bedtime Singulair 10 mg by mouth once daily Zanaflex 4 mg by mouth every 12 hours Lovaza 1 gram by mouth two times daily Thermazene Topical Cream one application two times daily Nyamyc one application two times daily Sucralafate 10 mL by mouth before meals and at bedtime Bactroban Ointment one application two times daily for 7 days Omeprazole 20 mg by mouth before breakfast Physical Exam: 216 lbs 5’4” BMI 37.5 kg/m2
HEENT: Oropharynx is somewhat dry and with significant erythema.
Extremities: Adequate pulses, but there is lower extremity edema bilaterally. Patient has open wound on right foot, leg with erythema that goes up to the thigh, also has yeast infection in the buttock area. Skin: Patient has yeast infection described as erythema and satellite lesions in the inguinal and under abdominal fold area.
Vital signs: Temp 97.9 BP 124/70 P 103 RR 16
Labs:
Na 120 mmol/l K 5.5 mmol/l Cl 93 mmol/l CO2 26 mmol/l BG 91 mg/dl BUN 83 mg/dl Cr 3.3 mg/dl CrCl 26.99 ml/min Ca 7.7 mg/dl Total Protein 4.9 g/dl Alb 2.5 g/dl Corrected Ca 9.22 mg/dl Anion Gap 11 mmol/L WBC 14.1 th/ul RBC 3.12 mil/ul Hgb 9.5 g/dl Hct 27.5% MCV 80 fl MCH 28.2 pg MCHC 31.8 g/dl Plt 386 th/ul