lOMoARcPSD|44613495
SHADOW HEALTH NURS7580 SOAP NOTE
ADVANCED HEALTH ASSESSMENT
2024
, lOMoARcPSD|44613495
SOAP Note: Infected foot wound
Subjective:
HPI: 28 y/o female presents to the clinic with complaints of foot pain. Patient
states that they scraped their foot on the edge of a cement block about a week
ago and sustained a wound. They went to the ER on were prescribed Tramadol
for pain and released. "A few days ago," they noticed the wound had gotten
worse with increased pain which they rated at 7/10 on a scale of 0-10 and
described as "sharp" and "throbbing". Patient also noticed redness, swelling, and
large amounts of pus coming out of the wound. The patient also reports
experiencing increased temperature (102 degrees Fahrenheit) the night before
their clinic visit.
PMH:
Past Medical History: Patient has a history of DM type II, dysmenorrhea,
headaches. Past Surgical History: None
Allergies: NKFA, reports allergy to penicillin and cats.
Patient reports having hives when they take penicillin and states that their eyes
get really itchy, they start sneezing a lot, and their "asthma starts to act up"
when they come close to cats. They deny taking any medications to treat their
allergies. Deny latex allergy
FHX:
Father died in a car accident, had DM type II Grandpa Jones (father's father) had
DM type II but died of colon cancer at age 78 or 80. Mom is alive, suffers from
HTN, grandmother (from dad's side) also suffers from HTN and high
cholesterol. Grandmother (from mum's side) died of a stroke at 73. Patient's
grandfather (mom’s side) died of a heart attack at 80 had HTN and high
cholesterol
SHX: Patient states she is single with no kids; has worked as a supervisor at a
copy and ship company since high school. Patient reports drinking alcohol only
socially, no smoking, denies current use of illicit drugs, but states they used to
smoke pot around the time they turned 20 year old
Medications:
Current medications include:
Acetaminophen 500-1000mg PO prn (headaches)
Advil 600 mg PO TID prn (menstrual cramps)
Tramadol 50 mg PO BID prn (foot pain)
Albuterol 90 mcg/spray, MDI 2 puffs Q4HR prn (last used " a few months
ago") Review of Systems:
SHADOW HEALTH NURS7580 SOAP NOTE
ADVANCED HEALTH ASSESSMENT
2024
, lOMoARcPSD|44613495
SOAP Note: Infected foot wound
Subjective:
HPI: 28 y/o female presents to the clinic with complaints of foot pain. Patient
states that they scraped their foot on the edge of a cement block about a week
ago and sustained a wound. They went to the ER on were prescribed Tramadol
for pain and released. "A few days ago," they noticed the wound had gotten
worse with increased pain which they rated at 7/10 on a scale of 0-10 and
described as "sharp" and "throbbing". Patient also noticed redness, swelling, and
large amounts of pus coming out of the wound. The patient also reports
experiencing increased temperature (102 degrees Fahrenheit) the night before
their clinic visit.
PMH:
Past Medical History: Patient has a history of DM type II, dysmenorrhea,
headaches. Past Surgical History: None
Allergies: NKFA, reports allergy to penicillin and cats.
Patient reports having hives when they take penicillin and states that their eyes
get really itchy, they start sneezing a lot, and their "asthma starts to act up"
when they come close to cats. They deny taking any medications to treat their
allergies. Deny latex allergy
FHX:
Father died in a car accident, had DM type II Grandpa Jones (father's father) had
DM type II but died of colon cancer at age 78 or 80. Mom is alive, suffers from
HTN, grandmother (from dad's side) also suffers from HTN and high
cholesterol. Grandmother (from mum's side) died of a stroke at 73. Patient's
grandfather (mom’s side) died of a heart attack at 80 had HTN and high
cholesterol
SHX: Patient states she is single with no kids; has worked as a supervisor at a
copy and ship company since high school. Patient reports drinking alcohol only
socially, no smoking, denies current use of illicit drugs, but states they used to
smoke pot around the time they turned 20 year old
Medications:
Current medications include:
Acetaminophen 500-1000mg PO prn (headaches)
Advil 600 mg PO TID prn (menstrual cramps)
Tramadol 50 mg PO BID prn (foot pain)
Albuterol 90 mcg/spray, MDI 2 puffs Q4HR prn (last used " a few months
ago") Review of Systems:
