SOAP Note 1 Brett Locke.docx - 1 Running Head LEFT LOWER EXTREMITY PAIN SOAP NOTE 1 Left Lower Extremity Pain Spring Arbor University Brett Locke 2 LEFT

SOAP Note 1 Brett Locke.docx - 1 Running Head LEFT LOWER...

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1 Running Head: LEFT LOWER EXTREMITY PAIN SOAP NOTE 1 Left Lower Extremity Pain Spring Arbor University Brett Locke
2 LEFT LOWER EXTREMITY PAIN SOAP NOTE 1 Name: P.R. Date : 2/24/2020 Time : 1000 DOB: 8/6/1964 Sex: Female Subjective CC: Left leg pain and rash HPI: Patient is a pleasant 55-year-old male who presents to the office with concerns of a red area to her left medial ankle. She first noticed the symptoms roughly one week ago. She experienced a cramping pain in her left calf for roughly 3 days and states this resolved on its own without intervention. There were no aggravating or alleviating factors. The pain did not radiate and was intermittent throughout the day. She rated the pain at 5/10 when at its worst. She complains of a small red patch of redness at the left medial ankle and has 7-8 additional “red spots” above her ankle to mid-shin. She denies pain to the calf. She states she has experienced similar symptoms in the past roughly one year ago after traveling on an airplane. She was evaluated at that time and was advised she was suffering from cellulitis. This was not treated with antibiotics. She has a history of pulmonary embolism in 2016 and has Factor V Leiden. She denies shortness of breath, chest pain, palpitations or irregular heartbeat, cough or sweating. She is not experiencing fever, chills or night sweats. She denies swelling to either lower extremity. Medications: ASA 81 mg po daily Calcium 600 mg po daily Coumadin 5 mg po daily Folic acid 1 mg po daily Losartan Potassium 100 mg po daily Methotrexate 2.5 mg, 10 tablets po weekly Norco 10-325 mg po TID prn Omeprazole 20 mg po daily Multivitamin 1 po daily Potassium Chloride 10 mEq po daily Allergies: Codeine – reaction: hives Lisinopril – reaction: cough PMI Illnesses/Injuries Childhood – Varicella Adult – Pulmonary embolism 11/2016, Factor V Leiden, Hypertension, Rheumatoid Arthritis, Back Pain, Neuropathy Hospitalizations/Surgeries: Appendectomy 1989
2 LEFT LOWER EXTREMITY PAIN SOAP NOTE 1 Total vaginal hysterectomy 2005 Laparoscopic cholecystectomy 2006 Carpal tunnel release, bilateral 2007 Right knee arthroscopy 2014 Vaccinations Influenza – 11/2019, Pneumovax – n/a, Tetanus – 1/2016, HPV – n/a, Hep B - childhood Health Maintenance: Last mammogram – 6/2019, no masses or suspicious lesions Last pap smear – n/a, pelvic exam 6/2019 Last colonoscopy – 5/16/2019 screening colonoscopy, no masses or suspicious lesions Last prostate exam – n/a FH: Stroke – father Diabetes – father, mother Lung disease – n/a HTN – father, mother Heart disease – father Cancer – n/a SH: Married for 20 years, has 2 grown children, both boys. She works for the Red Cross Disaster Relief and travels frequently. She has one dog (Shih Tzu/Poodle mix). Tobacco: denies smoking history Alcohol: Rarely drinks alcohol Illicit drug use: Denies Caffeine: Drinks 16 ounces of coffee daily ROS General: Denies weight change, fatigue, weakness, fever, chills or night sweats Cardiovascular: Denies HTN, murmurs, angina, palpitations, dyspnea on exertion, orthopnea, PND, edema Skin: Denies skin, hair or nail changes.

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