SOAP Note: Case of Cellulitis (Other (Not Listed) Sample)

SOAP Note: Case of Cellulitis Student's Name Department, Institutional Affiliation Course & Number Instructor Due Date SOAP Note: Case of Cellulitis Patient: Mary Symon, a 38-year-old female black American. Subjective (S) Chief complaint (CC): An irritated expanding area of skin in the right leg characterized by swelling, pain, and redness. History of present illness (HPI):  The 38-year-old female Black American presented with acute symptoms in the right leg marked by swelling, pain, and redness. The patient states that she had a cut injury caused by a sharp object three days before the appearance of localized symptoms, including swelling and pain. The swelling and pain have been progressively becoming worse. Past Medical History (PMH): Mary Symon is known to suffer from type 2 diabetes, which is well-managed with medication and lifestyle tactics. She also has a history of hyperlipemia and hypertension. Past Surgical History:  Her surgical history is noncontributory                                         Medications: Mary Symon is on PO glipizide and metformin (2.5 mg/250 mg) Metaglip tablets, PO Captopril 25 mg, and PO losartan 25mg. Allergies: She has no known allergies  Family History: Her father and mother are living with diabetes and hypertension. There is no known history from the rest of the family. Social History:  Mary Symon is living with her elderly parents. She is unmarried and has no children. She works as a receptionist in a local bank and is a caregiver for his aging parents, who require help managing their diabetes and hypertension conditions. She denies smoking and substance abuse, but reports occasional alcohol drinking with friends. Review of Systems (ROS) General: The patient reports acute right leg swellings, localized redness, pain, and headache. She denies chills, fever, and vomiting. HEENT: The patient reports blurry vision and uses eyeglasses for clarity. Denies earache and discharge. She denies runny nose and neck pain. She also denies nasal discharge /bleeding and aphthous ulcerations. Cardiovascular (CVS): She denies palpitations and chest pains. The patient reports hypertension and hyperlipidemia. Pulmonary: Mary denies coughing, shortness of breath, or chest pain. She also denies any lung problems, including asthma, pneumonia, or bronchitis. Gastrointestinal (GI): The patient denies vomiting, nausea, diarrhea, abdominal pain, or abdominal surgeries Musculoskeletal: Mary denies muscle pain, joint swelling, arm/leg weakness, or arthritis. She complained of right leg swelling. GENITOURINARY(GU): The patient denies any history of chronic kidney disease, sexually transmitted disease dialysis, dysuria, or hematuria.  Neurology: She denies dizziness, stroke, numbness, motor weakness, or seizures. Lymphatic systems: Mary reports painful swollen nodes in bilateral groins. Allergy: The patient repudiates any known allergy to pollen, food, latex, or other products. Objective (O) Vital sign observations: * Heart rate :88 BPM * BP: 132/92mmHg * Respiratory Rate: 22 Per min. * Temperature: 37.8 C * Oxygen saturation: SO2 of 98% on room air (RA) * Height 5' 3" * Weight 178 lbs.                 * BMP 31.5 Physical Examination General: Mary is alert and oriented, with no apparent distress. She is also well-dressed.  HEENT: She is normocephalic, has blurry vision, no ear or nasal discharge, while mucus membranes are moist. Her nose is symmetrical, and the trachea is at the midline. There is no lymphadenopathy or thyromegaly. The rest of the HEENT system is remarkable. Cardiovascular (CV): Negative for arrythmias and murmurs. Gallops are absent Pulmonary System: Lungs are clear upon auscultation and bilateral percussion. The respiratory rate is regular and unlabored, with no signs of distress. Abdomen: Bowel sounds are present. There is no organomegaly and tenderness upon palpation, and it is negative for psoas and obturator signs. There are no bruits and abdominal scars. Genitourinary (GU): An examination of genitalia is remarkably good. No masses, tenderness, or discharge. Cremasteric reflex is intact, Neurological: The patient has no focal deficits Skin: Her skin is warm/dry, with no rashes. No wounds, with the exception of the inflamed swollen localized area on the right leg. Cardiac: There are regular S1 and S2 sounds. No murmurs while the heart rate and rhythm are regular. There is no edema, not cyanosed, with capillary refill time of less than two seconds. Musculoskeletal: Swelling and redness on the right leg and increased warmth compared to the right, with small open skin wounds but with no drainage. The rest of the musculature is remarkable. Neurological: She is fully oriented to place and time with a good score of bilateral lower extremities and intact sensation. Assessment (A) Diagnosis: Cellulitis Differential Diagnosis (DDX): 1 Acute contact dermatitis:  Contact dermatitis is manifested by red, itchy rashes. These symptoms result from direct contact with a substance or specific allergens. However, the patient denied rashes or any known allergies. Contact dermatitis is marked by contact skin lesions as a result of contact with diverse allergens, irritants and other causative factors such as UV radiation, intrinsic factors such as autoimmune responses, or a combination of these factors (Novak-Bilić et al.,2018). Based on subjective and objective data, acute contact dermatitis is an unlikely diagnosis in this case. 2 Lymphedema Lymphedema is characterized by tissue swelling culminating from the accumulation of protein-rich fluid that is drawn from the body's lymphatic system. There is a vicious cycle that connects lymphoedema with cellulitis. Lymphoedema is a disorder that results from the accumulation of fluid within the interstitial spaces and may happen as a consequence of cellulitis. However, based on the history, assessment, and acute nature of symptoms, lymphedema is an unlikely diagnosis. 3 Osteomyelitis. Osteomyelitis could be an unlikely diagnosis because the patient had no fever, chills, bone pain, loss of appetite, general discomfort, or ill feeling, and limited, painful movement. The patient had no typical symptoms of osteomyelitis. Impression: Cellulitis diagnosis Based on the subjective and objective data, the probable diagnosis for this case scenario is cellulitis. The history of injury caused by a sharp object around the inflamed area and the presence of diabetes could suggest cellulitis. Some of the common risk factors for cellulitis include local factors in the affected limb, such as injuries, while general factors that can be considered risk factors such as obesity, smoking, alcohol misuse, and diabetes mellitus could also exacerbate exposure to cellulitis. Local factors that compromise skin integrity, thus, breaking the skin barrier, increased risk of cellulitis because compromised skin integrity leads to the provision of an entry points for micro-organisms. Thus, skin trauma, skin cuts or lacerations, and leg ulcers, which break the skin barrier, allow the increased risk of microbe’s entry, which would cause inflection, leading to cellulitis. Research evidence shows that about 75 % of cellulitis cases are associated with compromised skin integrity (Cranendonk et al.,2017). Typical cellulitis presentation of redness, pain, swelling, and heat with rapidly spreading erythema constitute primary clinical diagnosis parameters. Laboratory investigations such as cultures of blood, aspirates, or biopsies are unnecessary for diagnosing cellulitis. Cellulitis is an acute spread of bacterial infection, which mostly affects the dermis and subcutaneous skin layers, characterized by erythema, swelling, increasing warmth, increasing tenderness, and regional lymphadenopathy. It is commonly caused by streptococci and Staphylococcus aureus. Plan (P) Cellulitis requires urgent management to avoid increased spread to the rest of the body. Management of cellulitis aims to resolve symptoms, minimize cellulitis sequelae such as edema and ulceration, and reduce hospital admission length. The general measures for managing cellulitis include bed rest, skin and wound care, analgesia, and elevation of the affected leg (Dai et al.,2021). Cellulitis management strategies such as limb elevation and the use of narrow-spectrum antimicrobial therapies should be accompanied by treatment of comorbid disorders such as diabetes and vascular disease that exacerbate the cellulitis (Vijayalakshmi & Ganapathy, 2016). Antibiotics are primarily prescribed to eliminate the causative organism. However, oral antibiotics are recommended for milder forms of cellulitis with minimal systemic involvement. For instance, oral flucloxacillin can be used as the first-line antibiotic or intravenous flucloxacillin in severe cellulitis cases. Oral flucloxacillin can be combined with macrolides such as oral clarithromycin for patients who are allergic to penicillin, but intravenous clindamycin can substitute clarithromycin in cases of penicillin allergy. As a result of the increased risk of venous thromboembolism, which can be caused by an acute inflammatio...