*FOCUSED* SOAP NOTE: Tina Jones

SUBJECTIVE: Patient is a 28 y/o heterosexual, African American female

complaining of pain in her foot related to a recent injury about a week ago that
she incurred outside on a step (last tetanus booster 1 year ago). Patient sought
care in ED right after injury occurred as she thought she may have sprained an
anle; In ED X-ray, Rx pain medication as well as wound cleaning and dressing
completed. The past few days the pain has been increasing and she has
characterized the pain as constant, throbbing and sharp, fever at a high of 102*F,
non-odorous pus, swelling and redness near incision. Unable to bear weight on
foot due to 7/10 pain requiring patient to miss work. Relieving factors include
rest/elevation, advil and tramadol 50 mg PRN as Rx by ER MD. Aggravating factors
include walking/standing for work. Patient has been treating at home by cleaning,
applying Neosporin and bandaging.

“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:“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!”
PMH: Asthma (dx at age 2, requires albuterol for s/s 2-3 X per week, well
controlled, never intubated for episode, last exacerbation around 16-17 where
she required breathing treatment in hospital)
DM2: (Diagnosed at 24, does not check blood sugars at home, recent ER visit
increased glucose, was on metformin but DC’d 3 years ago r/t side effects
Gassy)
Allergies: DRUG: Penicillin: rash, hives, last reaction as child; ANIMAL: CATS
watery, itchy eyes, asthma exacerbation; ENVT: Dust: sneezing, wheezing, itchy
eyes
Surgical Hx: No surgeries
Family Hx:
Mother, 50 y/o: HTN, HLD
Father, deceased at 58 r/t car accident: HTN, HLD, DM2
Brother, 25 y/o: Obesity
Sister, 14 y/o: Asthma, never intubated
Paternal grandmother, 82: generally well health other then controlled HTN
Paternal grandfather, deceased in mid-sixties r/t Colon CA: DM2, HTN
Maternal grandmother, deceased 73 r/t stroke: HTN, HLD
Maternal grandfather, deceased 78 r/t stroke: HTN, HLD
Paternal Uncle: Addiction, alcoholism

Social Hx: Patient single, no children. Left monogamous relationship 2 years ago.
Works at a shipping company where she has been since high school and has just
been promoted to supervisor. She is currently a part-time student to obtain
bachelors in accounting, pays for school out-of-pocket. Denies financial and
transportation concerns and can afford medication however, patient does not
regularly check her blood sugar at home and tries to avoid the doctor at all costs
due to associated out-of-pocket costs. She was started on metformin however,
she disliked the side-effects r/t gas and discontinued about 3 years ago. No
current diabetic regime in place. Patient Lives with her mother and 14 year old
sister whom she provides care for some of the time however, due to her injury
has needed support from them. Support system based in family and heavy church
involvement. No current illicit drug use, brief marijuana use years ago, last
marijuana use around 21. Patient denies current and past cigarette smoking.
Patient denies use of psychedelics. Drinks socially, few drinks per week. Wears a
seatbelt in the car. Per patient, total number of partners is 3 and when patient is
sexually active does not use condoms 100% of the time, no previous abortions or
pregnancies, not currently on birth control as patient is not currently sexually
active. Never had a mammogram, last pap and STI testing was normal and was
about 4 years ago. Not currently vaccinated for flu, received all vaccinations as a
child, pneumonia vaccine several years ago. Tetanus about a year ago.

ROS:
General: Fever: highest temp 102*F, did not treat at home; Fatigue: r/t lack of
sleep due to pain, Weight loss: 10 pounds unintentional weight loss in the past
month; Patient reports polydipsia, polyphagia and polyuria
Skin:. Patient c/o 7/10 pain with difficulty bearing weight r/t pain. Per patient in
ER wound was swabbed and sent for cultures. Wound cleaned and re-dressed in
clinic. Patient c/o pus from wound which was non-odorous. Also of note,
darkened skin around neck area that she has noticed an increase in, in the past
several months. Patient reports increase in amount of hair and having to pluck
her “mustache”, she also noticed hair on her stomach and chin as well which has
gotten worse over the past several years. Patient reports dry skin on and legs
which she utilizes lotion for but reports reoccurring. Patient also reports zits
which are worse around her menstrual period.
Lungs: Patient reports wheezing around dust and cats occasionally which is
relieved with albuterol inhaler.
OB/GYN: Patient last PAP 4 years ago, not sexually active currently and is not on
birth control, when was sexually active did not use condoms all the time. Last
sexual activity 2 years ago with monogamous partner, no STI testing since 4 years
ago. Patient menses started at age 11. Periods have been heavy and irregular, last
period 3 weeks, frequency of periods are every 4-8 weeks and last 9-10 days.
Patient elicits zits and cramps with period. No mammogram and does not do
breast exams regularly as she does “not know what to feel for.
ENDOCRINE: DM2 diagnosed at 24 y/o, currently does not check blood sugar at
home and has discontinued metformin due to side effects.
PSYCH: Patient reports increased stress due to recent stress of father passing and
having to care for mother emotionally. Patient reports some depression after her
dad passed but has never taken any antidepressants. Patient reports strong
connection with religion in which she states God will not give her “more than she
can bear”. No SI or suicide attempts. Main worry currently is stress of her new
foot injury and getting back to work.

Acetaminophen 500-1000 mg
PO prn (headaches) • Ibuprofen
600 mg PO TID prn (menstrual
cramps) • Tramadol 50 mg PO
TID prn (foot pain) • Albuterol
90 mcg/spray MDI 2 puffs Q4H
prn (Wheezing: “when around
cats,” last use three days ago)
Medications:
Tramadol: 50 mg PO, TID PRN foot pain
Acetaminophen: 500-1000 mg PO PRN headaches
Ibuprofen : 600 mg PO TID PRN menstrual cramps
Albuterol: 90 mcg/spray MDI 2 puffs Q4H PRN Wheezing: “when around cats,”
also dust; last use three days ago
Metformin: Dose unknown, DC’d due to Side effects (gas mainly), last taken about
3 years ago
Patient denies use of vitamins and/or herbal supplements
OBJECTIVE:
Height: 170 cm, Weight: 90 kg; BMI:31
Blood sugar: 238
Vitals: BP: 142/82, RR: 19, HR:86, SPO2: 99% room air, temp: 101.1*F
Pain: 7/10
Pertinent Positives:
General: BP: 142/82, temp 101.1*F, pain 7/10
Endocrine: hyperglycemia: 238
Skin: 2 X 1.5 cm, 2.5 mm deep on right foot, plantar surface, wound appears, red,
swollen with purulent drainage. Darkened area around neck noted.
Pertinent Negatives:
Neuro: Patient A and O X 3 with appropriate affect and behavior. Speech is clear
and coherent. Patient appears both well-groomed and nourished. Pulse Ox, HR
and respirations all WNL. Patients face appears symmetrical without drooping.
HEENT: UTA
Respiratory: Patient appears to have unlabored breathing, without utilization of
accessory muscles. UTA breath sounds
CV:UTA
Musculoskeletal: UTA
GI: UTA
GU: UTA
Peripheral: UTA
PLAN: