Discussion Question
Please write a SOAP note for a patient who presents with CELLULITIS as a complaint. 2 sources minimum thank you
Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.
Subjective
CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective
Vital signs/BMI
Physical exam findings
Diagnostic results (include actual "results" or "findings" that you would expect for a certain scenario)
Assessment/Plan
Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem
Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up
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Subjective
Patient:
Initials: W.G
Age: 48 years
Sex: Male
Chief Complaint: “My leg is swollen and it hurts a lot.”
History of Present Illness:
W.G is a 48-year-old Mexican male who presents with a chief complaint of having a swollen and painful leg. He reports that the swelling and pain started after he stumbled and fell when working on the farm three days ago. After being pricked by a twig, he sustained a laceration on the left leg, which he cleaned using an antiseptic. The area around the laceration started swelling, and there was pain, which has progressed over time. He states that the swollen area is hot to touch and red than other parts of the leg. The symptoms are only on the left leg, and the right leg is fine. He also reports having some degree of fever in the last 12 hours. The patient reports taking OTC Motrin 400 mg twice daily to relieve the pain, but he did not notice any significant impact. He rates the leg pain as 6/10.
Past Medical History: History of Asthma diagnosed at six years; Has not had an asthma exacerbation since he was 26 years.
Past Surgical History: History of an appendectomy at 23 years.
Medications: Ventolin HFA for asthma attacks. OTC Motrin 400 mg to relieve leg pain.
Allergies: No known food or drug allergies. Allergic to dust mites and cold.
Immunizations: Immunization is up to date. The last influenza shot-6 months ago; TT shot- was 4 years ago; Fully immunized against COVID.
Family History: The maternal grandmother had Alzheimer’s and died from Stage IV lung cancer. The paternal grandfather had HTN and died from stroke. The patient’s mother has Rheumatoid arthritis, but the father has no chronic illness. The elder brother died from an RTA. Other siblings and children are alive and well.
Social History/Risk Factors: W.G is married and lives with his wife and three children (23, 20, and 17 years) in Blanco County, TX. He studied up to high school levels, and he currently works as a foreman on a ranch. He admits taking 3-4 beers about four times a week but denies tobacco smoking and using illicit substances. His hobbies include watching football and bullfighting. The patient states that he has at least three meals per day and sleeps 5-6 hours per day.
Review of Systems:
General: Positive for mild fever. Negative for chills, unexplained weight loss/gain, appetite disturbances, changes in activity level, or fatigue.
Head: Negative for headache, dizziness, or sinus tenderness or pressure.
Eyes: Denies changes in vision, blurred/double vision, eye redness, excessive tearing, or eye drainage. Last eye exam: 4 years ago.
Ears: Denies changes or difficulty in hearing, ear pain, or discharge.
Nose: Negative for loss of smell, runny nose, congestion, nasal, sneezing, or epistaxis.
Mouth/Throat: Negative for swallowing difficulty, difficulty chewing, mouth sores or lesions, sore throat, or voice hoarseness. Last dental exam: Two years ago.
Neck: Negative for neck stiffness, pain, neck nodule, or reflux.
Respiratory: Negative for breathing difficulties, cough, shortness of breath, dyspnea, or wheezing.
Cardiovascular: Negative for ankle edema, palpitations, chest pain/pressure, or dyspnea on rest or exertion.
GI: Negative for nausea/vomiting, acid reflux, heartburn, abdominal pain, flatulence, changes in bowel movement, pain with defecation, rectal bleeding, or hemorrhoids.
GU: Negative for painful urination, urinary frequency or urgency, or changes in urine color.
Musculoskeletal: Positive for tenderness and swelling of the left lower leg. Negative for joint pain, joint stiffness, backaches, or limitations in movement.
Neurological: Negative for generalized weakness, dizziness, tingling sensations, unsteady gait, memory loss, or mood changes.
Psychiatric: Negative for depression, anxiety, sleep disturbances, or suicidal thoughts/ideation/attempts.
Skin: Positive for laceration and erythema on the left leg. Negative for skin rash, hair loss, or nail discoloration.
Endocrine: Negative for excessive sweating, hair thinning/loss, heat or cold intolerance, increased urination, excessive thirst, or hunger.
Hem/Lymph: Denies bruising, delayed wound healing time, or history of anemia.
Objective
Vital Signs: Temp-100.22F; BP-, BP-118/76 (sitting position); HR-88; RR-16; SPO2- 99%
Height- 5’5, Weight- 185, BMI-30.8
General: Male patient in his late 40s. The patient is alert and not in any acute distress. He is oriented to person, place, and time. He maintains eye contact and speaks I normal volume and rate.
Neurological: Normal gait and balance. Muscle strength-5/5; CNs- intact.
HEENT: Head: Symmetrical and normocephalic; Eyes: White sclera, Pink conjunctiva, PERRLA; Ears: TMs are transparent and shiny; Nose; Symmetrical and midline. Nostrils are patent, Pink nasal mucosa; Throat: The tongue is pink and midline. The throat is vascular without swelling, exudates, or lesions.
Neck: Symmetrical with full ROM; The trachea is midline; The Thyroid gland is normal on palpation.
Lymph Nodes: Non-palpable cervical lymph nodes.
Respiratory: Respirations are smooth with no use of accessory muscles. Uniform chest movements. The chest is clear on auscultation.
Cardiovascular: No neck vein distension. Regular heart rhythm; S1 and S2 present.
GI: The abdomen is round with a scar on the right lower quadrant. Normoactive bowel sounds in all quadrants. No organomegaly on percussion. The abdomen is soft on palpation with no tenderness or masses.
Back: The spine is well-aligned.
Musculoskeletal: Active ROM in all joints. Normal posture. Edema of the left leg on the lower posterior aspect.
Skin: Erythema, tenderness, and warmth on a poorly demarcated posterior part of the left leg with no pus.
Psychiatric (affect, mood): The self-reported mood is nervous, and the affect is appropriate.
Diagnostic results:
Complete blood cell (CBC) count- Elevated WBCs
Assessment
Non-purulent Cellulitis:
Cellulitis manifest with non-necrotizing inflammation of the skin and subcutaneous tissue secondary to a primary infection. The cause of the inflammation is usually primarily due to the invasion of the skin by bacteria such as Staphylococcus aureus, Streptococcus pneumonia, and Vibrio vulnificus (Rrapi et al., 2021). Cellulitis has four classic symptoms: pain, swelling, warmth, and erythema (Ortiz-Lazo et al., 2019). Cellulitis is classified as either purulent or non-purulent.
Purulent cellulitis has pus in the infected skin part. In addition, patients with moderate to severe infection present with symptoms such as fever, chills, malaise, tachycardia, tachypnea, hypotension, and signs of toxicity (Ortiz-Lazo et al., 2019). Cellulitis is the presumptive diagnosis based on pertinent positive findings of erythema, pain, swelling, and warmth over the skin of the left leg after sustaining blunt trauma. Besides, the patient has a mild fever and elevated WBCs, which suggest an underlying infection.
Necrotizing fasciitis:
Necrotizing fasciitis is characterized by a rapid and progressive inflammatory infection of the fascia and secondary necrosis of the subcutaneous tissues. The hallmark symptoms of necrotizing fasciitis are intense pain and tenderness over the infected skin and underlying muscle (Chen et al., 2020). The severe pain often occurs before a patient develops a fever, malaise, and muscle pain. Physical exam findings include extensive erythema, purplish discoloration of the skin near the injury site, rapid burrowing, fever, and severe systemic reactions (Chen et al., 2020). Necrotizing fasciitis is a differential diagnosis based on the patient’s symptoms of erythema, pain, and tenderness of the left leg following blunt trauma. Besides, the patient developed a fever after the onset of pain. However, it is an unlikely primary diagnosis since the patient has no signs of infection of the fascia.
Erysipelas:
Erysipelas refers to a bacterial skin infection of the upper dermis that typically extends into the superficial cutaneous lymphatics. It mainly involves the lower extremities. Erysipelas is characterized by a tender, highly erythematous, an indurated plaque with a sharply demarcated border (Ren & Silverberg, 2021). Most patients present with a history of trauma. Prodromal symptoms, including high fever, malaise, chills, and usually begin before the onset of the skin lesion.
The prodromal symptoms typically occur within 48 hours of cutaneous involvement. Other typical symptoms include burning, pruritus, tenderness, and swelling (Ren & Silverberg, 2021). Erysipelas is a differential diagnosis based on pertinent positive symptoms of erythema, pain, swelling of the lower left extremity, and fever. However, the patient has no indurated plaque with a sharply demarcated border, which rules out, and the fever occurred after cutaneous symptoms, which rule out Erysipelas as a primary diagnosis.
Plan
Further diagnostic testing: Blood culture to identify or rule out bacteremia.
Pharmacological treatment: Levofloxacin 500 mg PO once a day.
Levofloxacin is as a fluoroquinolone. It is indicated in non-purulent cellulitis since it has abroad-spectrum activity against gram-positive and gram-negative aerobic organisms (Ortiz-Lazo et al., 2019).
Non-pharmacological: Immobilization and elevation of the affected leg to reduce swelling (Rrapi et al., 2021). Use cool, wet dressings on the affected part of the left leg to alleviate local discomfort.
Patient Education: The patient will be advised to complete the antibiotic dose to avoid resistance. He will also be instructed to keep the affected leg area clean and dry. In addition, he will be advised to maintain good hand hygiene and adequately clean any future abrasions on the skin (Rrapi et al., 2021).
Follow-up: The patient will be scheduled for a follow-up after two weeks to assess response to treatment and evaluate for any complications from the cellulitis.
References
Chen, L. L., Fasolka, B., & Treacy, C. (2020). Necrotizing fasciitis: A comprehensive review. Nursing, 50(9), 34–40. https://doi.org/10.1097/01.NURSE.0000694752.85118.62
Ortiz-Lazo, E., Arriagada-Egnen, C., Poehls, C., & Concha-Rogazy, M. (2019). An Update on the Treatment and Management of Cellulitis. Actualización en el abordaje y manejo de celulitis. Actas dermo-sifiliograficas, 110(2), 124–130. https://doi.org/10.1016/j.ad.2018.07.010
Ren, Z., & Silverberg, J. I. (2021). Burden, risk factors, and infectious complications of cellulitis and erysipelas in US adults and children in the emergency department setting. Journal of the American Academy of Dermatology, 84(5), 1496–1503. https://doi.org/10.1016/j.jaad.2020.11.021
Rrapi, R., Chand, S., & Kroshinsky, D. (2021). Cellulitis: A Review of Pathogenesis, Diagnosis, and Management. Medical Clinics, 105(4), 723-735. https://doi.org/10.1016/j.mcna.2021.04.009