Various Skin Conditions Diagnosis (Research Paper Sample)

SOAP ANALYSIS
Name of Patient: Mark McDonald Age: 58 years old
Chief Complaint (CC): the patient has pain in his left leg, redness and the leg is swollen.
History of Present Illness
This 58 years old male has been having left lower extremity pain, erythema, and edema of the left lower extremity. According to Mark the pain started three days ago and has been getting worse each day. The leg then got red and become progressively painful. Before the pain, he had stumbled and fell down the stairs though he lay down on his left leg. There were no open wounds hence, he used ice to relieve the pain he was feeling. He did not apply any medication or take any.
Medications
Medications currently under use:
Coreg, Inderal, Lantus, Aspirin, Protonix
Allergies: The patient get allergies when he takes Sulfa drugs and tetracycline
Past Medical History: GERD, Depression, Hypertension, Obesity
PAST SURGICAL History: Laser eye Surgery, Arthroscopy of left shoulder
Significant Family History: Family has history of hypertension and diabetes. Father is diseased from cancer. Brother is currently dealing with diabetes and hypertension.
Social History: Mark is divorced. Has three kids. Two have moved out but one is currently living with him. Recently retired but runs a coffee shop. Denies drinking or taking illicit drug abuse.
Review Systems:
General/Constitutional: Complains of Left leg pain, redness, and swelling. Occasional fever
HEENT: No blurry vision, denies ear pain or discharge, no running nose, or neck pain.
Cardiovascular: Has History of CAD, hypertension, and hyperlipidemia. Denies chest pains. Complains of only left leg swelling.
Pulmonary: No history of asthma, Lung problem, or bronchitis.
Genitourinary: History of chronic kidney pain, not on dialysis. No hematuria
Gastrointestinal: Patient denies having abdominal pain
Musculoskeletal: Denies having muscle pain, or arms. No leg weakness reported
Neurological: Denies having seizures, strokes, or paresthesias.
Vital Signs: T 37.9 BP 156/83 HR 68 RR 18
HEIGHT 5’4’’ WEIGHT 169 Ibs BMP 30.5
PHYSICAL EXAM:
Appearance: appropriately dressed, has morbidity obese, face becoming grimy especially after touching left leg.
HEENT: hair is normally distributed, EOMI, PERRI, AND Sclera clear, conjunctiva pink. Normal lids. Normal ears without pain or tenderness. No deformity in nose or discharge noted. No thyromegaly. Trachea at midline.
Cardiac: Normal, no murmurs noted. Rate and Rhythm is regular. No cyanosis
Respiratory: Clear to auscultation. Rate of respiratory is regular and done without effort.
Abdomen: bowel sounds normal. No abdominal scars or bruits.
Musculoskeletal: No joint effusion or swelling
Extremities: left lower extremity is erythematous in the arch. No ulcerations noted and there are no open wounds. No drainage witnessed. The left lower extremity is tender and there is increased temperatures.
Neurological: sensation is grossly intact. Oriented to person, time, and place.
LAB/DIAGNOSTIC TESTS: Comprehensive metabolic panel
Blood count normal
US left lower extremity
IMPRESSION/PLAN
Diagnosis: CellulitisLO3.119
Differential Diagnosis
Acute Dermatitis- patient is complaining of fever and pain especially in the reddened area
Osteomyelitis- occasional fever. No discomfort or ill pain. No pain in bones