Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example

Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example

Patient Name (Initials only): T.N.

DOB: March/6/1995

Gender: Female

Date examined:  __________

CHIEF COMPLAINT “I scraped my foot some time back, and did not seek medical attention thinking it would self-heal. However, the wound looks awful and the pain is worsening.”(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
HISTORY OF PRESENT ILLNESS,
The medical history gathered for this interview came primarily from T.J. Additional information came from her medical file. T.J. is an obese African American woman in her 28s who is awake, alert, and oriented to people, places, time, and self. T.J. arrives today for her first primary care appointment, complaining of an infected plantar foot wound that has been present for one week and exhibiting signs of a temperature of 101.1°F(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) . She denies taking any medication for high temperatures. The patient states that the infected area is swollen, red, and warm when touched. She describes a 7/10 throbbing, intense pain radiating to the ankle. According to T.J., the discomfort worsened two days ago. She’s been using Tramadol for pain since a week ago, three times a day, morning, noon, and night, as per an E.R. doctor’s prescription. The patient reports no odor, 2 days of off-white discharge, and an inability to bear weight. She applies Neosporin ointment twice daily, in the morning and the evening, after cleaning the wound with hydrogen peroxide. The pain is worsening, but an x-ray of the foot taken by the E.R. revealed no fractures or broken bones. (Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example)  
PAST MEDICAL HISTORY
Childhood & Adult Illness
The patient was diagnosed with asthma as a child, and she is currently treating symptoms using inhalers. She reports childhood hospitalizations for asthma attacks.She has uncontrolled type 2 diabetes, diagnosed at age 24. The patient denies checking blood sugar. She has been prescribed Metformin and reports three years of non-adherence.She reports painful menstrual cramps.T.J. has an irregular menstrual cycle. The last menstrual period was three weeks ago. She reports six periods a year.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Previous Hospitalizations/Surgery/Trauma T.J. denies past hospitalization or surgeries
Medications Tramadol 50 milligrams by mouth for painMetformin 500 milligramsProventil inhaler – 2 puffs by mouth Albuterol inhaler 90 micrograms – 2 -3 puffs by mouthThe counter Acetaminophen gel extra strength 500 mg 2 tablets as needed for headacheOver-the-counter Advil 2 tablets by mouth as needed for menstrual crampingDenies use of vitamin or herbal supplements    
Allergies/Adverse Reactions She is allergic to cat dander, which causes her to experience difficulty breathing, sneezing, and itchy eyes.Dust allergies cause her breathing difficultiesShe develops rash and hives when she takes penicillin The patient has no food allergies(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Immunizations: Childhood immunizations are up-to-date; Tetanus booster one year ago. The patient denies varicella and Flu vaccines. Health Maintenance: She had her last pap smear and gynecological exam 4 months ago. T.J. denies regular breast exams. She reports intake of sweets and carbohydrates, drinks diet soda, and denies adding salt to foods and regular exercise.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
FAMILY HISTORY
She reports significant diabetes, hypertension, and high cholesterol in her family. Her mother is alive but has hypertension and high cholesterol. T.J.’s father died at 58 years from a car accident. He had hypertension and high cholesterol diabetes. Her maternal grandmother died at 73 from a stroke and suffered from hypertension and high cholesterol. Her maternal grandfather died at 80 years from a heart attack and suffered from hypertension and high cholesterol. T.J.’s paternal grandfather died in the mid-60s from colon cancer but also had hypertension and diabetes. The paternal grandmother is 82 years old and alive but suffers from hypertension and Hyperlipidemia. T.J.s uncle drinks ETOH. Her brother is alive and overweight but has no other health issues. T.J.’s sister is alive and has controlled asthma.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
SOCIAL HISTORY The patient has lived with her mother since her father passed away. T.J. reports a history of marijuana use and denies tobacco use and vaping. She reports drinking two or three alcoholic drinks per occasion and denies illicit drug use. She attends college for her bachelor’s in accounting. The patient denies financial hardship and identifies her mother as her support system.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
REVIEW OF SYSTEMS
Constitutional
She reports fatigue and unintentional 10-pound weight loss, a fever at 101.1
Eyes
T.J. reports blurred vision and watery eyes when reading
Ears/Nose/Throat
Ears: denies hearing changes or ear pain. Nose: denies sneezing or change in the sense of smell, sinus pain, or pressure. Throat: denies difficulty swallowing- dry mouth – swollen lymph nodes(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Mouth / Dental
Denies tooth decay and gum disease; the last visit to the dentist was one year ago. T.J. denies speech problems, sinus drainage, taste, snoring
Breast
Denies lumps, nipple discharge, family history of breast cancer, self-breast exam
Cardiovascular Denies chest discomfort or palpitations(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Respiratory Denies cough or chest tightness, difficulty breathing except during asthma attacks, and dyspnea on exertion. T.J. has a history of asthma since she was 2 years old.
Gastrointestinal
Denies nausea or vomiting, abdominal pain, no changes in bowel or bladder pattern, or constipation; denies diarrhea.
Genito-Urinary
Denies change in urinary pattern; denies dysuria or incontinence. She is heterosexual. T.J. denies a history of STDs and reports being sexually inactive since her last boyfriend one year ago
Male Reproductive
NA
Female Reproductive
T.J. Reports an irregular period; the last period was three weeks ago. She has no STI history and denies odor. Reports using condoms as the primary method of contraception.
Musculoskeletal Denies arthralgia and myalgia, arthritis gout or limitations in her range of motion, and trauma or fractures. She reports pain in her ankle due to a recent injury.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Neurological
The patient denies syncopal episodes or dizziness, paresthesia, change in memory or thinking pattern, disturbances or problems with coordination, and seizure history. T.J. reports headaches when studying and a history of recent falls.
Skin
Denies rashes, itching, or bruising. Reports change in skin color on the neck has become darker. She has an open wound on her right plantar foot.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Endocrine
T.J. reports polyurea, polyphagia, polydipsia, and fatigue. She denies heat or cold intolerance or shedding of hair. The patient reports unintentional weight loss.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Hematologic/Lymphatic:
T.J. denies bruising, bleeding, and anemia. She has no history of blood transfusion or thrombolytic disorders.
Psychiatric(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
She denies a history of anxiety or depression, apart from when her father died in a car accident. She denies fatigue, sleep disturbances, delusions, or mental health history. T.J. denies suicidal and homicidal history or ideation.
PHYSICAL EXAMINATION (Please describe your findings from inspection, palpation, percussion, & auscultation and use the term “deferred” if you did not examine that area.)
Vital signsHt: 5’8 Wt 142 BMI: 21.6 
 Temp:97.4FPulse:85B.P.: 110/68 
 R.R.: 18 Pain: 7/10   
General Appearance
The patient appears healthy, dressed appropriately for the season, clean and well-groomed, with well-kempt hair. The patient seems in pain while moving or stepping due to the wound.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Head Normocephalic and atraumatic. The patient experiences frequent headaches.
Eyes Sclera anicteric, No conjunctival erythema, PERRLA(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Ears/Nose/Throat
Oropharynx red, moist mucous membranes
Mouth / Dental
Teeth appear healthy and aligned. No odor or teeth decay.
Neck Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.
Respiratory No wheezes and respirations are easy and regular.
Cardiovascular
Although the patient’s heartbeat and rhythm are regular, murmurs and other sounds are coming from her chest. The patient’s heart rate is constant, and capillaries refill in two seconds.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Gastrointestinal No nausea or vomiting, no abdominal pain or bowel changes
Genitourinary/Gynecological No changes in Urinary pattern, no dysuria or inconsistency, no STD, reports being sexually active with boyfriend.
Lymphatic No axillary lymphadenopathy or swelling on palpation(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Skin No rashes or bruising, raker skin on the neck, and an open wound to the right plantar foot.
Back, Extremities, Musculoskeletal
No arthralgia and myalgia, no arthritis gout or limitations in range of motion, no trauma or fractures, reports pain in the ankle.
Neurological No syncopal episodes or dizziness, no paresthesia, no change in memory or thinking pattern, denies disturbances or problems with coordination, reports headaches when studying.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Psychiatric No anxiety or depressive report, fatigue, sleep disturbances, or suicidal or homicidal ideation.
Previous Diagnostic Testing/Lab Results No previous diagnosis or lab tests
Differential Diagnoses with Rationale
T89.03 Infected Wound With Cellulitis:  T.J. reported scrapping her foot and not seeking medical attention because she hoped it would heal by itself. However, the wound has worsened, and she is in excruciating pain. She also reports that she experiences swelling, redness, and warmth when touched. She states throbbing, sharp pain, which she rates at 7/10, radiating to the ankle. Miss Jones says the pain has worsened in the past two days. The swelling, redness, warmth when touched, and pain might indicate cellulitis. Cellulitis often manifests as a warm, erythematous region that is poorly defined, edematous, and sensitive to palpation. It is an acute bacterial infection that inflames the subcutaneous tissue around it and the deep dermis. Anything that could weaken the skin’s protective layer, such as cuts, punctures made during surgery, fissures between the toes, insect and animal bites, and other skin infections, are risk factors for cellulitis (Brown & Watson, 2022). Cellulitis is more likely in patients with concomitant conditions such as diabetes mellitus, venous insufficiency, peripheral arterial disease, and lymphedema. T.J. has uncontrolled type 2 diabetes, which might be a factor causing the wound not to self-heal.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example)    
E11. 621 Diabetic Foot Infection:  Individuals with uncontrolled diabetes can develop hard-to-heal ulcers. T.J. may have a diabetic foot infection, given that the wound she thought would heal by itself is not healing. Diabetic foot infections can range from a simple instance of cellulitis to full-blown gangrene in the presence of local trauma like an injury and microvascular dysfunction (Murphy-Lavoie et al., 2022). Patients with diabetic foot infection might present with swelling, drainage, blood in shoes or socks, large calluses or cracked heels, blisters, redness, sores, splinters, and scrapes. T.J. experiences swelling, redness, and warmth when touched. Diabetes might be a factor for why the wound is not healing by itself, but the diagnosis was refuted due to lack of purulence. However, if not taken care of, the wound would worsen to the point of amputating the foot.  (Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
L08.9: Local infection of the skin and subcutaneous tissue, unspecified:   Just like T.J. is experiencing skin inflammation, patients presenting with local infection of the skin and subcutaneous tissue, unspecified, experience rash on the skin due to conditions by pathogens like bacteria or skin trauma from an injury (WHO, 2019). Skin in the affected areas may appear red or warmer than usual, similar to what T.J. is experiencing, the swelling, redness, and warmth when touched. Blisters may have developed on inflamed skin. Pain could be present in the affected areas, similar to T.J.’s, as she is experiencing pain. She rates it at 7/10. It is a potential diagnosis, but it was refuted because the primary symptoms inclined more to potential cellulitis, including swelling, severe pain, and redness.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
      ASSESSMENT T89.03 Infected Wound with Cellulitis Cellulitis is the confirmed diagnosis per the history of the present illness and the physical assessment of the affected foot. It is established that T.J. scrapped her foot but assumed the wound would heal by itself, only to worsen. She experiences swelling, redness, and warmth when touched, which are primary symptoms of cellulitis. She rates her pain at 7/10, which is severe and another sign of potential cellulitis. Cellulitis mainly presents as a warm, erythematous region poorly defined, edematous, and sensitive to palpation. It is an acute bacterial infection that inflames the subcutaneous tissue around it and the deep dermis. No abscess or purulent discharge is associated with the infection, which supports the diagnosis because T.J. did not report purulent discharge (Brown & Watson, 2022). Normal skin flora and other microorganisms can penetrate the dermis and subcutaneous tissue when the skin breaks, which is the case with T.J. scrapping her foot and breaking the skin. When these bacteria are introduced below the skin’s surface, cellulitis can result from a severe, superficial infection that affects the deep dermis and subcutaneous tissue (Brown & Watson, 2022). Cellulitis is more likely in patients with concomitant conditions such as diabetes mellitus, venous insufficiency, peripheral arterial disease, and lymphedema. T.J. has uncontrolled type 2 diabetes, which increases the risk of developing cellulitis. Given these conditions, cellulitis was confirmed. (Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
PLAN Diagnostics: Based on medical history and physical exam. Medications: Five-day oral antibiotic therapy. Prescribe trimethoprim-sulfamethoxazole 800 mg/160 mg twice and cephalexin 500 mg every 6 hours to treat the nonpurulent cellulitis and address any risk for MRSA infection (Brown & Watson, 2022). Referral/Consults: Refer the patient to a dermatologist to evaluate the potential for other skin conditions and infections. Education: Educate the patient to clean and dry the woundEducate the patient on applying a bandage or gauze to protect the wounded skin.Advise the patient to avoid antibiotic ointments or creamsAdvise the patient to adhere strictly to the medication prescribed Follow Up: Return to the hospital after a week to check progress.(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
REFERENCE Brown, B. D., & Watson, K. L. H. (2022). Cellulitis. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549770/ Murphy-Lavoie, H.M., Ramsey, A., Nguyen, M. (2022, July 4). Diabetic Foot Infections. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441914/ WHO. (2019). ICD-10 Version:2019. ICD-11. https://icd.who.int/browse10/2019/en#/L00(Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example) 
Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example
Documentation Of History and Physical Exam Soap Note Comprehensive Nursing Essay Example 1

Reference

https://www.ncbi.nlm.nih.gov/

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