NR 509 Brown Susan Week 1 Soap Note

NR 509 Brown Susan Week 1 Soap Note

 History of Present Illness (HPI) Chief Complaint (CC) " I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it's looking pretty nasty. And the pain is killing me!" CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Patient fell 1 week ago going down the back steps of her residence. The patient twisted her ankle and consequently scraped the plantar surface of her right foot. Care was sought one hour after the incidence in the emergency room. The wound was elvaluated, x-rayed, and cleansed; the patient was discharged to home with a prescription of Tramadol 50mg for pain. The patient reports the pain began to increase two days ago stating, " suddenly my foot was killing me." Patient is unable to weight bear and has missed several days from work. Reports pain 7 out of 10. The foot is swollen, red, and hot to the touch. There is non odorus pus draining from the wound.Patient began to run a fever last night. Current temperature is 101.1 Location Plantar surface of the right foot, radiating to right ankle Duration Injury occurred 1 week ago. Pain, swelling, drainage worse for 2 days Characteristics Pain is throbbing and becomes sharp when she bears weight on right foot Aggravating Factors Weight bearing Relieving Factors Pain medication and non-weight bearing Treatment Tramadol 50mg 2 tablets three times a day, cleanses the wound with soap and water, and applies Neosporin twice a day Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.