Description
Introduction
For this assignment, you will be given a case study. Review the information provided and answer the questions. Be sure to cite your references. Look at the case study as if the subject is a patient in your office seeking care. What are your immediate concerns? What needs to be done for them? Be thorough and succinct in your responses. Your submission must be in SOAP note format. I WILL ATTACH FORMAT BELOW.
Case Study/SOAP Note:
Julia King is a 50y/o white female who presents to the office with c/o wound to her left foot for the past few days. States she tripped and fell while barefoot, scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours, the wound has had “smelly” drainage. Has been experiencing some numbness, tingling, and pain, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Her last tetanus shot was 15 years ago. Patient PMHx significant for DM II. States that she takes her medications when she remembers, and does not always check her blood sugar.
PMHx:
Asthma: no hospitalizations for exacerbation.
DM II
PSHx:
Denies
SHx:
Smokes 1 pack of cigarettes per day for 5 years.
ETOH: socially
Illicit drugs: denies
FHx:
Mother 71 y/o with a history of diabetes and obesity
Father 72 y/o with a history of HTN
Brother 51 alive and well
Sister 48 with a history of HTN and diabetes
No family history of colon, ovarian, or uterine cancer
No history of CAD or PVD
Medications:
Metformin: 500mg BID po – did not take the last few days
Albuterol MDI: 2 puffs every 6 hours prn – last used 3 days ago
Singulair: 10mg po daily
Allergies:
PCN: hives and facial swelling
LNMP: N/A
G2p2
ROS:
General: denies any weight changes, fatigue, or fever; + body aches
Skin: denies any rashes; + wound to left foot
HEENT: denies headache, head injury, dizziness, lightheadedness; denies any vision changes; denies any hearing changes, tinnitus, vertigo, earache; denies any nasal congestion, discharge, nose bleeds or sinus tenderness; denies any sore throat, difficulty swallowing
Neck: denies any swollen glands, pain
Breasts: denies any pain, discharge
Respiratory: denies any dyspnea; positive cough and wheezing
CV: denies any chest pain, edema
GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools
PV: denies swelling in face, hands. No history of leg cramps or past clots in extremities. States has swelling in left foot
GU: denies frequency, urgency, burning; denies vaginal discharge, itching, sores
MS: denies any weakness, numbness, erythema, twitching, or pain. No h/o of backaches or fx’s. No joint pain, tenderness, or history of head trauma. Positive for left foot pain
Psych: denies nervousness, depression
Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE
Heme: denies any easy bruising
Physical Exam:
Vital signs:
5 (tympanic), 180/100, 90, 22, O2 sat 95% on RA
Height: 5’5ʺ
Weight: 250 lb
Blood glucose: 230 (Fasting; states has not eaten yet today)
Patient awake, alert, oriented x 4 with no apparent distress (NAD)
Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drainage; + surrounding erythema extending up 7 cm proximally
HEENT: head nontraumatic, normocephalic
Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted
Ears: bilateral TM with good cone of light and intact
Nose: mucosa pink, septum midline; no sinus tenderness appreciated
Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate
Neck: supple; trachea midline; without any lymphadenopathy
Resp: regular and unlabored; lungs with end expiratory wheezing throughout
CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated
Abdomen: soft, non-distended; BS + x 4; no tenderness with palpation; no CVA tenderness with percussion
Genitalia: deferred
Rectal: deferred
Extremities: warm and dry with edema to left foot; calves supple, non-tender
PV: No swelling noted to hands, feet or face. Positive swelling to left foot
MS: + swelling to left foot; + tenderness of 2nd–4th left metatarsals; + left pedal pulse; Cap refill < 2 sec. Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves I-XII intact Address the following items: List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential. At this time, what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how? What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out? What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each. What is your comprehensive plan of care? Include your rationales.
Unformatted Attachment Preview
Name:
Pt. Encounter Number:
Date:
Age:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
Sex:
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms,
location where the symptoms began, aggravating or alleviating factors, pertinent positives and
negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related
to the present illness.
Medications: (List with reason for med )
Allergies: (List with reaction)
Medication Intolerances:
Past Medical History:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung
disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone
diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance
use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS Student to ask each of these questions to the patient: “Have you had any…..”
General
Cardiovascular
Weight change, fatigue, fever, chills, night
Chest pain, palpitations, PND, orthopnea, and
sweats, and energy level
edema
Skin
Delayed healing, rashes, bruising, bleeding or
skin discolorations, and any changes in lesions
or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea,
pneumonia hx, and TB
Eyes
Corrective lenses, blurring, and visual changes
of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and
black, tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and
throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain,
fracture hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis,
weakness, paresthesias, and black-out spells
Psychiatric
Depression, anxiety, sleeping difficulties,
suicidal ideation/attempts, and previous dx
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst,
increase hunger, and cold or heat intolerance
OBJECTIVE
Weight
BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions
appropriately. Slightly somber affect at first and then brighter later.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA.
EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray
with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal
turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no
occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is
nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills
two seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No
hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of
the skin.
Genitourinary
Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in
normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted.
Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no
lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On
bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly
distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness.
Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males:
Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is
firm).
Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft,
though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis—point of care test done today in the office- results positive for nitrites and blood,
negative for leukocytes.
Urine culture collected in office—pending results, sent to lab
Wet prep collected in office—pending results, sent to lab
Assessment
o
Include at least three differential diagnoses
Provide rationale for each differential diagnosis
▪
o
Final diagnosis
Pathophysiology of primary and rationale for choosing as final
▪
Plan
o
o
o
o
o
o
o
o
Medications
Non-pharmacological recommendations
Diagnostic tests
Patient education
Culture considerations
Health promotion
Referrals
Follow up
Name:
Pt. Encounter Number:
Date:
Age:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
Sex:
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms,
location where the symptoms began, aggravating or alleviating factors, pertinent positives and
negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related
to the present illness.
Medications: (List with reason for med )
Allergies: (List with reaction)
Medication Intolerances:
Past Medical History:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung
disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone
diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance
use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS Student to ask each of these questions to the patient: “Have you had any…..”
General
Cardiovascular
Weight change, fatigue, fever, chills, night
Chest pain, palpitations, PND, orthopnea, and
sweats, and energy level
edema
Skin
Delayed healing, rashes, bruising, bleeding or
skin discolorations, and any changes in lesions
or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea,
pneumonia hx, and TB
Eyes
Corrective lenses, blurring, and visual changes
of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and
black, tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and
throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain,
fracture hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis,
weakness, paresthesias, and black-out spells
Psychiatric
Depression, anxiety, sleeping difficulties,
suicidal ideation/attempts, and previous dx
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst,
increase hunger, and cold or heat intolerance
OBJECTIVE
Weight
BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions
appropriately. Slightly somber affect at first and then brighter later.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA.
EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray
with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal
turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no
occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is
nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills
two seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No
hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of
the skin.
Genitourinary
Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in
normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted.
Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no
lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On
bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly
distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness.
Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males:
Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is
firm).
Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft,
though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis—point of care test done today in the office- results positive for nitrites and blood,
negative for leukocytes.
Urine culture collected in office—pending results, sent to lab
Wet prep collected in office—pending results, sent to lab
Assessment
o
Include at least three differential diagnoses
Provide rationale for each differential diagnosis
▪
o
Final diagnosis
Pathophysiology of primary and rationale for choosing as final
▪
Plan
o
o
o
o
o
o
o
o
Medications
Non-pharmacological recommendations
Diagnostic tests
Patient education
Culture considerations
Health promotion
Referrals
Follow up
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