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SOAP NOTE
| Name: V.N | Date: 8/23/2020 | Time: 0800 |
| Age: 53 years | Sex: Male | |
| SUBJECTIVE | ||
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CC: “I am having pain in my right leg”
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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
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Medications: None
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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
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Family History Father is having cardiac heart failure related disease while the mother is having high blood pressure
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Social History The patient is a university graduate and he is married with two children. He denies taking alcohol or smoking.
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| ROS | |
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General The patient denies weight change, fatigue, fever, chills, and the night sweats.
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Cardiovascular The patient denies pain in the chest, no orthopnea, no palpitations. |
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Skin Denies any delayed process of healing, bruises, rashes, bleeding or discoloration of the skin, and any moles or lesions
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Respiratory No coughing, no pneumonia, no wheezes, no dyspnea, no hemoptysis
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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
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Ears Denies pain of the ear, hearing problem, ringing of the ears, or any ear discharge
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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 |
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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. |
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Breast Denies any changes or bumps |
Neurological The patient denies syncope, seizures, short-lived paralysis, weakness, paresthesias, or black-out spells. |
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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. | ||
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Skin The patient is brown, warmer, clean, and intact. Absence of the lesions or rash |
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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 |
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| Cardiovascular Normal S1 and S2 with regular rate and rhythm. No splitting in the heart sounds heard. No murmur. No friction rub, no edema. | ||
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Respiratory There is stable, regular, and easy respiration. The auscultation of the bilateral lungs is clear. |
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Gastrointestinal No obese, active BS in all the four quadrants, soft and non-tender abdomen, and no hepatosplenomegaly. |
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Breast No masses or tenderness of the breast. Absence of the discharge and dimpling, wrinkle, and skin color is the same
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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 |
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Musculoskeletal There is no full ROM in the patient’s extremities. The movement is limited |
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Neurological The patient is having clear speech, good tone with no erect posture. There is unstable balance and abnormal gait. |
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Psychiatric He is alert and oriented, clean, able to maintain eye contact, soft speech, and appropriately responding to the questions asked. |
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Lab Tests Urinalysis – pending Urine culture – pending Wet prep – pending
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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 |
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| Diagnosis | ||
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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
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| Plan/Therapeutics | ||
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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.
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| 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 |
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