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SOAP NOTE

Name: V.N

Date: 8/23/2020

Time: 0800

Age: 53 years

Sex: Male

SUBJECTIVE

CC: “I am having pain in my right leg”

HPI: The patient states that the pain started four days ago and it is in the right lower leg. The patient states that his right leg feels tight and he rates the pain as 7/10

Medications:
None

PMH
No past medication history indicated by the patient
Allergies: NKDA

Medication Intolerances: Denies any intolerance to the medication

Chronic Illnesses/Major traumas Denies having any chronic diseases

Hospitalizations/Surgeries: Denies any surgical procedure or hospitalization

Family History
Father is having cardiac heart failure related disease while the mother is having high blood pressure

Social History The patient is a university graduate and he is married with two children. He denies taking alcohol or smoking.

ROS

General
The patient denies weight change, fatigue, fever, chills, and the night sweats.

Cardiovascular
The patient denies pain in the chest, no orthopnea, no palpitations.

Skin
Denies any delayed process of healing, bruises, rashes, bleeding or discoloration of the skin, and any moles or lesions

Respiratory
No coughing, no pneumonia, no wheezes, no dyspnea, no hemoptysis

Eyes
Denies corrective lenses, no blurring, no changes in her vision.

Gastrointestinal
Denies abdominal pain, no constipation, no history or present hepatitis, no ulcers, denies black tarry stools

Ears
Denies pain of the ear, hearing problem, ringing of the ears, or any ear discharge

Genitourinary/Gynecological
Patient denies the presence of the urge or frequency burning, denies change in the urine color and any menstrual issue. Admits to be sexually active. Denies having been diagnosed with STDs

Nose/Mouth/Throat
Denies sinus issues, dysphagia, nose bleeding, discharges, dental illness, hoarseness, pain.

Musculoskeletal
Admits swell near his right leg which is painful and tight. Denies history of fracture or osteoporosis.

Breast
Denies any changes or bumps

Neurological
The patient denies syncope, seizures, short-lived paralysis, weakness, paresthesias, or black-out spells.

Heme/Lymph/Endo
The patient is HIV negative. He denies bruises, has undergone blood transfusion, no night sweats, has swollen glands, increased hanger, denies thirst, cold and heat intolerance.

Psychiatric
Denies sleeping problems, anxious, and suicidal thoughts or attempts.

OBJECTIVE

Wt 68kg BMI 18.7

Temprature 97

Blood Pressure 122/62

Ht 6’3’’

Pulse 68 beats/min

Respiration 16

General Appearance The patient looks well in no acute distress. He is alert and oriented and is responding to the questions in appropriate manner.

Skin
The patient is brown, warmer, clean, and intact. Absence of the lesions or rash

HEENT
Normocephalic, atraumatic and with no lesions of the head. The hair of the patient is evenly distributed.
Eye is having intact EOMs with no injection of the conjunctival or scleral.
Ear is having patent canals, easily visualized landmarks, and the bilateral TMs
Nose pink mucosa with normal turbinates
Neck is supple without palpable lymphadenopathy, there is no occipital nodes, nodules, nor thyromegaly.
There is moist and pink oral mucosa. The pharynx is non-erythematous with no exudate. The teeth is in good shape with normal dental arrangement

Cardiovascular Normal S1 and S2 with regular rate and rhythm. No splitting in the heart sounds heard. No murmur. No friction rub, no edema.

Respiratory
There is stable, regular, and easy respiration. The auscultation of the bilateral lungs is clear.

Gastrointestinal
No obese, active BS in all the four quadrants, soft and non-tender abdomen, and no hepatosplenomegaly.

Breast
No masses or tenderness of the breast. Absence of the discharge and dimpling, wrinkle, and skin color is the same

Genitourinary
Both testes are palpable, no masses or lesions, no hernia, no urethral discharge. prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm

Musculoskeletal
There is no full ROM in the patient’s extremities. The movement is limited

Neurological
The patient is having clear speech, good tone with no erect posture. There is unstable balance and abnormal gait.

Psychiatric
He is alert and oriented, clean, able to maintain eye contact, soft speech, and appropriately responding to the questions asked.

Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep – pending

Special Tests
Complete blood count: to help in the knowing the number of leukocytes
MRI: to detect the presence of thrombus
D-dimer: to help in excluding thromboembolic illness

Diagnosis

Differential Diagnoses
Deep Venous Thrombosis: it is characterized by pain and the swelling of the limb that is non-specific. The patient have warm, swollen, and tender leg.
Cellulitis: this is a non-necrotizing inflammation of the skin and the subcutaneous tissues. It has symptoms such as swelling, warmth, pain, and erythema
Pulmonary Embolism: occurs as a result of the blood clot clogging in an artery in the lung and blocking the flow to the lung.
Diagnosis
o Deep Venous Thrombosis

Plan/Therapeutics

o Plan:
· Further testing: ultrasound to see clear picture of the arteries and the veins to monitor how the blood flows. Venogram can also be ordered to be followed by the x-ray to determine the location of the DVT
· Medication: Painkillers such as acetaminophen; heparin, lovenox, arixtra, and warfarin to help in the thinning of the blood. Thrombolytic drugs are also prescribed to help in the breaking of the clots.
· Education: The patient is advised not to sit for long to reduce the development of the blood clots. The patient is advised to adopt exercise such as knee pulls that involves the bending of the leg and raising of the knee towards the chest. The patient is also taught on the importance of ankle circles exercise where the feet are lifted off the floor while the patient tries to draw the circle with the toes in one direction for a few seconds
· Non-medication treatments: Keeping of the arm elevated through the use of the stool or chair. Wearing compression stockings to help in the prevention of pooling and swelling. It also helps in increasing the blood flow.

Evaluation of patient encounter: The patient is evaluated based on the reduction of the pain and the ability to make movement with a lot of ease after discharge from the facility

References

Murrell, D. (2019, November 13). Everything You Want to Know About Deep Vein Thrombosis (DVT). healthline: https://www.healthline.com/health/deep-venous-thrombosis
Ouellette, D. R. (2019, October 16). Pulmonary Embolism (PE). Medscape: https://emedicine.medscape.com/article/300901-overview