Soap Notes

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  • Topic: Renal failure, Liver function tests, Renal function
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  • Published : July 5, 2013
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J.L. SOAP NOTE
Subjective
J.L. is a 63-year-old white female who presented to the ER with right lower extremity pain and swelling with subsequent changes to the skin, including formation of bullous ulcers. She had blistering over the past four days that started to enlarge. The doctor prescribed her Bactrim. Erythema, swelling, and pain progressively got worse.  She denies any fever or chills. 

PMH:
COPD, Hypertension, Diabetes mellitus, Osteoporosis, Fibromyalgia, Osteoarthritis, Morbid obesity
Allergies:
Morphine
Nubain

Social History:
Patient denies smoking and alcohol use. She is disabled and lives at home with her husband. Objective
Medications:
Clonazepam 0.5 mg by mouth once daily
Simvastatin 10 mg by mouth at bedtime
Singulair 10 mg by mouth once daily
Zanaflex 4 mg by mouth every 12 hours
Lovaza 1 gram by mouth two times daily
Thermazene Topical Cream one application two times daily
Nyamyc one application two times daily
Sucralafate 10 mL by mouth before meals and at bedtime
Bactroban Ointment one application two times daily for 7 days
Omeprazole 20 mg by mouth before breakfast

Physical Exam:

216 lbs5’4”BMI 37.5 kg/m2

HEENT: Oropharynx is somewhat dry and with significant erythema.

Extremities: Adequate pulses, but there is lower extremity edema bilaterally. Patient has open wound on right foot, leg with erythema that goes up to the thigh, also has yeast infection in the buttock area.

Skin: Patient has yeast infection described as erythema and satellite lesions in the inguinal and under abdominal fold area.

Vital signs:
Temp 97.9BP 124/70P 103RR 16
Labs:
Na 120 mmol/lK 5.5 mmol/lCl 93 mmol/lCO2 26 mmol/lBG 91 mg/dlBUN 83 mg/dlCr 3.3 mg/dlCrCl 26.99 ml/minCa 7.7 mg/dlTotal Protein 4.9 g/dlAlb 2.5 g/dlCorrected Ca 9.22 mg/dlAnion Gap 11 mmol/LWBC 14.1 th/ulRBC 3.12 mil/ulHgb 9.5 g/dlHct 27.5%MCV 80 flMCH 28.2 pgMCHC 31.8 g/dlPlt 386...
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