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.
CASE STUDY
JOURNAL DETAILSIntroductionCase StudyInstructions
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
INSTRUCTION
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.
- Julia King, a 50-year-old white female, presents with a wound on her left foot due to a recent fall.
- The wound has been draining with a foul odor over the past 24 hours.
- She experiences numbness, tingling, and pain in her foot.
- Her medical history includes type 2 diabetes (DM II) with inconsistent medication adherence.
- She has a history of asthma, smokes one pack of cigarettes a day for five years, and has a family history of diabetes and hypertension.
- Medications include Metformin (not taken in the last few days), Albuterol MDI (last used 3 days ago), and Singulair.
- She has no known allergies.
- No recent menstruation (LNMP), G2P2.
O:
- Vital signs: Blood pressure 180/100, pulse 90, respiratory rate 22, O2 saturation 95% on room air, tympanic temperature 5°F, fasting blood glucose 230.
- Physical exam shows a 4 cm wound on the anterior left foot with crusting and purulent drainage, surrounded by erythema extending 7 cm proximally.
- End expiratory wheezing noted in the lungs.
- Swelling in the left foot with tenderness of the 2nd–4th metatarsals.
- Capillary refill is less than 2 seconds.
- No significant abnormalities in the HEENT, neck, abdomen, genitalia, rectal, or neuro exams.
A:
- Differentials for Wound Infection: a. Cellulitis: Given the erythema, purulent drainage, and surrounding warmth, cellulitis is a possible diagnosis. b. Abscess: Purulent drainage, localized swelling, and pain could suggest an abscess. c. Osteomyelitis: If the infection spreads, or in the presence of chronic non-healing wounds, osteomyelitis should be considered due to the presence of diabetes and non-healing wounds.
- Differentials for High Blood Pressure: a. Hypertension: Elevated blood pressure may be due to essential hypertension given the patient’s age and family history. b. Pain-related increase in BP: The pain from the foot injury could cause temporary elevated blood pressure. c. Non-adherence to Metformin: Poor medication adherence can worsen blood sugar control and contribute to hypertension.
- Differentials for Foot Swelling: a. Cellulitis: The foot swelling could be due to cellulitis, an infectious process. b. Deep Vein Thrombosis (DVT): Consider DVT as a cause of unilateral foot swelling, especially with risk factors such as smoking. c. Diabetic Peripheral Neuropathy: Neuropathy can cause swelling and numbness in the foot.
I:
- For the wound infection, order a lower extremity ultrasound to evaluate for the possibility of abscess or DVT. This will help rule in or out an abscess and assess for vascular compromise. A wound culture should be taken to identify the causative pathogen.
- For the high blood pressure, consider repeating blood pressure measurements in a calm setting after addressing the acute issue. Discuss long-term blood pressure management and encourage lifestyle modifications. Assess renal function and perform a basic metabolic panel.
- For the foot swelling, consider a D-dimer blood test to evaluate for DVT. Also, order a foot X-ray to assess for any underlying bone involvement.
- Perform a comprehensive metabolic panel (CMP) to evaluate renal function and electrolyte levels. A complete blood count (CBC) can help identify any signs of infection, anemia, or other blood disorders. Hemoglobin A1c should be checked to assess long-term diabetes control.
- Comprehensive Plan of Care:
- For the wound infection, prescribe broad-spectrum antibiotics (e.g., cephalexin) to cover potential pathogens until culture results are available. Advise proper wound care and follow-up.
- Address the high blood pressure by discussing lifestyle modifications (smoking cessation, weight management, dietary changes) and consider blood pressure medications based on repeat readings.
- For the foot swelling, initiate anticoagulant therapy if DVT is confirmed, and consult vascular surgery for evaluation if necessary.
- Encourage regular medication adherence for diabetes and adjust Metformin dosage as needed.
- Provide education on foot care and the importance of blood sugar control for a diabetic patient.
- Schedule a follow-up appointment for wound evaluation and diabetes management.
SOAP Note is not intended for a final diagnosis but to guide initial assessment and management decisions. Consultation with a specialist may be needed for further evaluation and treatment.