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Charnita Anderson
Soap Note #2
Kevin Prince
Date of Encounter: 11/7/13
Location of encounter: Dr. Philomena Ukwade: Internal medicine Clinic
Identifying information:
Patient initials- B.H.
DOB (Age) – 55 y.o.
Gender/race- Female/Caucasian
SUBJECTIVE
Chief Complaint:
“My stomach has been hurting since yesterday, and I just don’t feel good.”
Duration: She has been experiencing these symptoms for 24 hrs.
History of Present Illness:
Location- Pain in lower right side of abdomen.
Quality- Patient describes the discomfort as a constant dull, achy pain that occasionally feels like
she is being stabbed.
Severity- Patient reports pain level of 7 out of 10.
Timing- Patient admits to abdominal pain starting one day ago. She was cleaning and vacuuming
her house and the pain started while she was doing this.
Setting- Patient admitted to his leg pain started after he took a brisk walk with his dog. Five days
later he woke up early in the morning feeling short of breath. His wife wanted to call 911, but he
refused. Patient admitted to the feeling resolving after a few minutes, but his symptoms have
worsened in the past 24hrs.
Exacerbating factors- Patient admits that he becomes short of breath, and his leg starts to hurt
when he walks short distances.
Associated factors- Patient also admits to having chills and fever for the past 24hrs. He also feels
fatigued, weak with occasional dizziness.
Alleviating factors- Patient admits that rest helps with the shortness of breath, and Tylenol
decreases his temperature. He admits that nothing seems to decrease his leg pain.
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Current Health History:
Allergies: Patient has no known medicine, food, or environmental allergies.
Medications: Losartan/HCTZ 100mg/25mg, Glimepiride 4 mg, Niaspan 500mg, Amlodipine
10mg, Viagra 100mg, Aspirin 80mg, Tylenol PRN.
Immunization Status: Patient is up to date on his immunizations.
Habits: Patient denies smoking, ETOH, or recreational drugs.
Health Maintenance Practice:
Last physical exam- 1/16/13
Last prostate exam- 1/16/13
Self- testicular exams: Patient denies performing self-testicular exams.
Nutrition- Patient admits to eating well balanced meals every day. His wife cooks breakfast,
lunch, and dinner every day.
Exercise: Patient takes a brisk walk daily.
Relevant Past Medical History:
General: Patient admits to being in good health generally.
Surgeries: Patient admits to having an appendectomy in 1990.
Blood transfusions: Patient denies ever requiring a blood transfusion.
Hospitalization: Patient admits to being hospitalized in 1990 for appendicitis and in 2010 for
cellulitis of the right leg.
Serious accidents/ Injuries/ fractures: Patient denies any serious accidents.
Major illnesses:
Childhood illnesses: Patient cannot recall having any childhood illnesses.
Adult illnesses: Patient admits to having appendicitis (1990), cellulitis (2010), and Flu
(2012). Hypertension, diabetes mellitus type II, hyperlipidemia, and arthritis.
Limitations of ADL: Patient admits that he is unable to walk from one room to another without
feeling short of breath. He feels that he cannot complete his normal daily activities without
feeling fatigued and weak.
Social History
Home living conditions: Patient lives with his wife and dog in Friendswood, Texas
Occupation: Patient is retired. He was an electrician for 25 years.
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Economic Resources/concerns: Patient denies any economical concerns at this time.
Military record: Patient has never been a member of the military.
Religious or cultural considerations: Patient has no religious affiliation, or cultural considerations
that would affect his medical care.
Patient’s explanatory model:
Patient believes he has cellulitis again, but admits that he not sure why he is so short of breath.
Family History:
Patient’s mother had a history of heart disease. She died from a heart attack. Patient’s father had
a hypertension and diabetes. Pt. had one brother who died from complications of diabetes
mellitus type II.
Review of systems:
General: Patient admits to feeling fatigued and weak.
Diet: Patient admits to eating well balanced meals. His wife cooks all his meals.
Skin: Patient admits that his right leg is red, and feels warm to touch with swelling.
Head & Neck: Patient denies headaches, migraines, neck pain, history of head, or neck injury.
Lymph: Patient denies any swelling or tenderness of the lymph nodes.
Eyes: Patient denies redness, discharge, burning, watering, pressure or pain behind the eyes.
Patient wears corrective lens for near-sided vision.
Ears: Patient denies any tinnitus, pain, or discharge of the internal or external ear.
Nose: Patient denies any nasal congestion, discharge, burning, or pain of the nose.
Throat & mouth: Patient denies any symptoms of sore throat, canker sores, phlegm, bleeding
gums, or hoarseness.
Cardiovascular: Patient denies chest pain, palpitations, or history of heart condition.
Chest/Lungs: Patient admits to having shortness of breath with exertion that improves with rest.
He denies wheezing, coughing, phlegm, or history of asthma/COPD.
GI: Patient denies nausea, vomiting, excessive gas, diarrhea, constipation, hemorrhoids, or
bloody stools.
Peripheral Vascular/Musculoskeletal: Patient admits to having weakness, warmth, swelling,
redness, and tenderness with throbbing pain in the calf of his right leg. Pt. denies history of gout
or deep vein thrombosis.
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Neurological: Patient admits to dizziness when he becomes short of breath. Pt. denies numbness,
tingling, headaches, fainting, change in vision, or seizures.
OBJECTIVE
General Description: Patient appears very weak. H: 71in. W: 231.4 lbs.
Vital Signs: T: 102.0 F (oral), B/P: 113/52(sitting/left arm), HR: 93, RR: 22, O2%: 90%
Skin: Calf and ankle of right leg is edematous with severe erythema. Affected skin in area
appears tight and shiny.
Head, Eyes, Ears, Nose, & Throat (HEENT): Head: Shape, size, and appearance of head are
normal. Hair is soft to touch. No pain or sensitivity when sinuses are palpated. Eyes: No
discharge, no redness, vision is normal. Patient wears prescriptive contacts. Ears: Minimal
amount of scaly, dry lesions to the left ear lobe. No drainage from internal or external ear. No
pain on palpation. Tympanic membrane is light pink in color. Hearing acuity is within normal
range. No hearing devices being used. Nose: No redness in nares, no discharge present. Throat:
No redness, or drainage from throat.
Lymph: Lymph nodes are soft, mobile, and non-tender. No swelling present.
Cardiovascular: Heart tones are clear & crisp. No bruits or murmurs present upon auscultation.
Apical pulse is strong and bounding. No jugular vein distention present. No thrills upon
palpation.
Chest/Lungs: Chest is symmetric. Lungs sounds are clear bilaterally and resonant. Chest is
symmetrical anteriorly & posteriorly.
GI: No scars present on the abdomen. No masses present. No tenderness or guarding on
palpation of all abdominal quadrants. Liver’s edge is palpable. Bowel sounds are present in all
quadrants. No bruits auscultated over abdominal arteries. No CVA tenderness present.
Peripheral vascular/musculoskeletal: Right calf and ankle is warm to touch, severe erythema
with pitting edema. Popliteal pulses are strong and bounding +2, dorsalis pedis and posterior
tibial pulses are slightly diminished +1. Decreased ROM in right knee and ankle due to severe
edema. Varicose veins present in lower extremities bilaterally. Homan’s sign is negative
bilaterally. Unstable gait. Pt. using cane to help with stability. No varicose veins present.
Neurological: Pt. is alert & oriented to person, time and place and cooperative. No numbness or
loss of sensation in lower extremities elicited with sensory testing. DTR’s are present and within
normal range +2.
Diagnostic/Lab Data: None currently. See attached plan of care.
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ASSESSMENT
Medical Diagnosis:
Cellulitis: is an infection of the deeper layers of the skin. Cellulitis has a particular predilection
for the lower extremities, where the venous stasis predisposes to infection. In patients with
diabetes mellitus, streptococci and staphylococci are the predominant pathogens of cellulitis
(Andreoli, 2010). The assessment findings are erythema, warmth, edema, pain, fever, and
lymphadenopathy (Hensley & Hollier, 2011). This diagnosis was ruled in due to the fact that the
patient exhibited all of the symptoms associated with cellulitis. His right leg had severe
erythema, warm to touch, pitting edema, and he was febrile. It was also ruled in as the diagnosis
because the patient is a diabetic and has a history of cellulitis in a lower extremity.
Differential Diagnosis:
Venous Thromboembolic Disease (VTE): encompasses both deep vein thrombosis (DVT) and
pulmonary embolism (PE). The incidence of VTE is higher in men than in women. Most DVT
starts in the calf veins. Pain and swelling are the major complaints from patients with DVT;
however, a large number are asymptomatic. Homan sign may be present, along with a low grade
fever and dilated superficial veins. PE occurs when a thrombus dislodges from the deep veins of
the upper or lower extremities. The classic symptoms of acute PE are the sudden onset of
dyspnea and pleuritic chest pain, and chest pain. Most common physical findings are tachypnea
and tachycardia (Andreoli, 2011). A chest x-ray and venous ultrasound was ordered to help rule
out these diagnoses.
Osteomyelitis: This condition should be suspected in any patient who complains of pain in long
or flat bones and walks with an antalgic limp. Fever, chills and vomiting are usually present in
acute osteomyelitis. The hallmark is a constant local pain that progressively worsens. Chronic
osteomyelitis is characterized by relapse of pain, erythema, swelling, or evidence of purulent
discharge (Dain, 2012). This diagnosis was ruled out due to the fact that the patient did not have
and purulent discharge.
PLAN
Therapeutics:
* This patient was sent to the emergency room due to the decline in this patient’s health status.
He is short of breath with decreased oxygen saturations, fever, tachypnea, pain, erythema, and
warmth in right leg. All these symptoms suggest infection. Due to the fact that this patient is a
geriatric patient with a history of diabetes and cellulitis, he needs to be admitted to the hospital
for intravenous antibiotics.
For stable patients, elevation of the extremity to help prevent edema, and moist heat for pain
relief can be used as non-pharmacologic management (Hensley & Hollier, 2011).
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Pharmacotherapeutics:
*If this patient was stable he could have been treated with oral antibiotics. First Generation
Cephalosporins, Sulfa Agents, clindamycin, rifampin, and linezolid are all options for the
treatment of cellulitis depending on the type of bacteria causing the infection (Hensley & Hollier,
2011).
Diagnostic Tests: Culture and sensitivity, CBC, blood culture, ESR, venous doppler study to rule
out DVT, chest x-ray to rule out PE, peripheral artery disease testing (Andreoli, 2011).
Education: Patient should be educated of ways to prevent cellulitis. Good skin hygiene,
especially when there is a break in the skin, avoid swimming when skin abrasion is present, and
early treatment of upper respiratory infections (Hensley & Hollier, 2011).
Referrals: Patient was referred to the ER.
Follow up: Patient is to return to the clinic one week after he is discharged from the hospital.
References
Andreoli, T.E., Benjamin, I. J. and Wing, E.J. (2010). Andreloli and Carpenter’s CECIL
Essentials of Medicine (8th ed.). Saunders
Dains, J.E., Baumann, L.C., & Scheibel, P. (2012). Advanced health assessment and clinical
diagnosis in primary care (4th ed.). St. Louis: Elsevier Science.
Hensley, R., Hollier, A. (2011). Clinical guidelines in primary care: A reference and review
book. Lafayette, La: Advanced Practice Education Associates.
Stalbow, J. (2004). Preventing cellulitis in older people with persistent lower limb edema. British
Journal of Nursing, 13 (12), 725-732.
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Article Critique
The article that I chose to read and critique was written by Julie Stalbow. It was
published in the British Journal of Nursing in 2004. The article speaks of the causes of edema
and how edema can lead to the development of cellulitis. Stalbow discussed the things that could
also prevent cellulitis. My patient has had hypertension, hyperlipidemia, and diabetes mellitus
for many years. Due to these chronic health conditions he suffers with edema in his lower
extremities. Inappropriate compression of edematous limbs is particularly hazardous and may
precipitate tissue necrosis or ulceration. The risk of arterial disease increases with age (Stalbow,
2004). If my patient had been educated in the past to wear compression hose every day, it is
possible that this case and his previous case of cellulitis could have been prevented. Stalbow
discusses how the health provider should be educating patients regarding prevention. She also
focuses on the importance thorough assessment skills of the health provider. Accurate
assessment of the underlying etiology will reduce the consequences of inappropriate treatment
The focus needs to expand to encompass and educate the public, health and social services
(Stalbow, 2004). This article was very interesting because most articles that I read were
discussing how to treat cellulitis in geriatrics instead of preventing it. Cellulitis is a preventable
and more education is needed regarding this topic for patients who are at such high risk.
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