Cellulitis SOAP Notes
A patient presents in Urgent Care with concerns about her right lower leg. The patient is a Hispanic, older female (67 years old) who is allergic to PCN, has a very meager income, and shares that she had a bug bite on her leg and after a couple of days, that area of her skin feels hot and slightly tender. What questions might you ask? What treatment would you prescribe? Follow up? Please provide this information with your SOAP note , along with your reference.
Sample Paper
What questions might you ask?
Some of the questions that should be asked during patient examination include what kind of a bug bites the patient; this will help identify the possibility of poisoning, causing the skin to be tender and hot. In case the patient is unaware, she should be asked to tell where she encountered the bug. The patient should be asked whether she is experiencing. Since the bite, the care provider should ask if the patient has taken any medications. If yes, she should provide the details, for example, if the medication was just a pain killer. The patient should be asked about her health history, including diagnosis of any chronic conditions or current illnesses (Meyer et al., 2022).
The patient should also provide details on whether she is taking any prescribed medication currently, and if she is, the care provider should seek to know the kind of prescriptions and for what purposes. Information concerning the health history and current medication is important in determining the type of medication to be prescribed to avoid any negative interactions that can harm the patient (Meyer et al., 2022).
The care provider should also ask about the patient’s social history, including whether she lives alone or with family members, her participation in social activities, and the general support system for the patient. This information will be important in identifying individuals that can be instructed to provide care for the patient as she recovers since she is quite elderly. The social support can able be identify the bug that bites her, which can help decide the best drug options for the patient (Meyer et al., 2022)
What treatment would you prescribe?
The drugs to be prescribed for this patient include antibiotics and pain killers. Clarithromycin 500mg tablets would be the most appropriate prescription for this patient. She is allergic to penicillin, and therefore a macrolide would be an appropriate alternative. The full dosage is taken for seven days. Pain killers, including acetaminophen, would be appropriate to manage the pain she is experiencing (Dutta et al., 2021).
Follow up?
The follow-up should be after seven days when she will have completed the Clarithromycin dosage. If the symptoms are not resolved, she should return to the clinic for further assessment (Meyer et al., 2022).
Soap note.
| Name: C. Y | Age: 67 | Sex: Female | Ethnicity: Hispanic |
| Subjective | |||
| Chief complaint:
“The right lower leg feels hot and tender following a bug bite.” |
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| HPI:
The patient is a Hispanic 67-year-old female that presents to the clinic complaining that her skin on the right lower leg feels tender and hot. This was after she had a bug bite a couple of days ago. She is allergic to penicillin. |
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| Medications:
Unknown medication history. |
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| PMH
Allergies: allergic to penicillin. |
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| Review of the systems (ROS) | |||
| General;
No fever, chills, coughs, fatigue, loss of appetite, or weight loss. |
Cardiovascular;
Denies chest pain, palpitations, or peripheral edema |
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| Skin
Denied skin rash, dryness, |
Respiratory:
Denied coughs, or wheezing sounds, |
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| Eyes:
Denies changes in vision, photophobia, or irritation |
Gastrointestinal:
Denies abdominal pain, constipation, abnormal movements, ulcers, or nausea |
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| Ears:
Denies loss of hearing, pain, or discharge. |
Genitourinary
Denies incontinence or other abnormalities. |
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| Nose/Mouth/Throat
Denies sore throat, dysphagia, dental discharges, nose bleeds, sinusitis, throat hoarseness, or pain. |
Musculoskeletal
Hot and tender skin on her lower right leg. |
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| Breast,
N/A |
Neurological
Denies tremor, paralysis, ataxia, headaches, dizziness. |
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| Heme/Lymph/Endo:
Denies bruising, swelling in the extremities and lymph nodes, heat intolerance, increased hunger and thirst, |
Psychiatric
Denies depression, suicidal ideation, hallucination |
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| Lab Tests: None | |||
| Diagnosis:
Insect bites infection; Given the patient complaint, it is likely that the area where she was bitten has been infected. Often bug bites resolve after a couple of days since most bugs are not poisonous. However, in some cases, the bite wound continues to worsen, which indicates the possibility of an infection. |
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| Plan/Therapeutics
The drugs to be prescribed for this patient include antibiotics and pain killers. Clarithromycin 500mg tablets would be the most appropriate prescription for this patient. She is allergic to penicillin, and therefore a macrolide would be an appropriate alternative. The full dosage is taken for seven days. Pain killers, including acetaminophen, would be appropriate to manage the pain she is experiencing (Dutta et al., 2021). Follow-up: The follow-up should be after seven days when she will have completed the Clarithromycin dosage. If the symptoms are not resolved, she should return to the clinic for further assessment (Meyer et al., 2022) . |
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References
Dutta, M., Patra, S., Saxena, S., & Roychowdhury, A. (2021). Antimicrobials: Targets, Functions, and Resistance. Biomolecular Engineering Solutions for Renewable Specialty Chemicals: Microorganisms, Products, and Processes, 77-109. https://onlinelibrary.wiley.com/doi/abs/10.1002/9781119771951.ch3
Meyer, A. F., Borkovskiy, N., Hessedal, T., & Murray, M. (2022). Does This Bite Need an Antibiotic?. The Journal for Nurse Practitioners. https://www.sciencedirect.com/science/article/abs/pii/S1555415522000137
