2LEFT LOWER EXTREMITY PAIN SOAP NOTE 1Name: P.R.Date :2/24/2020Time : 1000DOB: 8/6/1964Sex: FemaleSubjective CC: Left leg pain and rashHPI: 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 dailyCalcium 600 mg po dailyCoumadin 5 mg po dailyFolic acid 1 mg po dailyLosartan Potassium 100 mg po dailyMethotrexate 2.5 mg, 10 tablets po weeklyNorco 10-325 mg po TID prnOmeprazole 20 mg po dailyMultivitamin 1 po dailyPotassium Chloride 10 mEq po dailyAllergies: Codeine – reaction: hivesLisinopril – reaction: coughPMIIllnesses/InjuriesChildhood – VaricellaAdult – Pulmonary embolism 11/2016, Factor V Leiden, Hypertension, Rheumatoid Arthritis, Back Pain, Neuropathy Hospitalizations/Surgeries: Appendectomy 1989
2LEFT LOWER EXTREMITY PAIN SOAP NOTE 1Total vaginal hysterectomy 2005Laparoscopic cholecystectomy 2006Carpal tunnel release, bilateral 2007Right knee arthroscopy 2014Vaccinations Influenza – 11/2019, Pneumovax – n/a, Tetanus – 1/2016, HPV – n/a, Hep B - childhoodHealth 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 – fatherDiabetes – father, motherLung disease – n/a HTN – father, motherHeart disease – father Cancer – n/aSH: 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 historyAlcohol: Rarely drinks alcoholIllicit drug use: Denies Caffeine: Drinks 16 ounces of coffee dailyROS General: Denies weight change, fatigue, weakness, fever, chills or night sweatsCardiovascular: Denies HTN, murmurs, angina,palpitations, dyspnea on exertion, orthopnea, PND, edemaSkin: Denies skin, hair or nail changes.