Assignment: History and Physical Note Template

Assignment: History and Physical Note Template

Assignment: History and Physical Note Template

Chief Complaint or Reason for Consult: “Swollen and painful leg”

History of Present Illness (HPI): S.W. is a 48-year-old White male who presented to the ED with a chief complaint of swelling and pain in the leg. He reported that the symptoms began three days ago after camping in the woods during the weekend. The swelling was on the right lower leg and the left leg had no symptoms. He reports that he fell when walking in the woods and got pierced by a blunt stick that left a minor laceration on the right leg but the pain abated shortly afterward. However, when he got back home he noted that the lacerated area had some swelling and he started feeling some pain, which worsened over time. He mentions that the swollen leg is red and hot to touch. He also has a mild fever.  He had taken Tylenol which relieved the pain to some degree but the swelling has persisted.   He rates the leg pain at 5/10.

Past Medical History:  Hyperlipidemia; diagnosed at 42 years. History of obesity since his 30s.

Past Surgical History: Hemorrhoidectomy at 40 years

ORDER A CUSTOMIZED, PLAGIARISM-FREE PAPER HERE

Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us

Family History: The Paternal grandmother died from Lung Cancer.

Maternal grandfather had DM and Kidney failure.

Maternal uncle has DM, HTN, and Renal failure.

Mother has osteoarthritis.

Siblings and children are alive and well.

Social History: S.W. is an insurance agent working in a top insurance firm. He has a Masters degree in Marketing. He is married and has two children 20 and 15 years. He takes beer 3-4 bottles per day regularly and smokes 1PPD. He enjoys traveling and camping. He sleeps 6-7 hours per day.

Allergies: Allergic to nuts- cause a rash.

Home Medications: OTC Tylenol 500 mg PRN for leg pain.

Hospital Medications: Atorvastatin 20 mg OD for hyperlipidemia.

Review of Systems:

• CONSTITUTIONAL: Positive for mild fever. Denies chills, unexplained weight loss/gain, appetite disturbances, changes in activity level, or fatigue.
• EYES: Denies changes in vision, blurred/double vision, eye redness, excessive tearing, or eye drainage.
• EARS, NOSE, and THROAT: Denies changes or difficulty in hearing, ear pain, or discharge. Negative for loss of smell, runny nose, sneezing, or epistaxis. Negative for swallowing difficulty or sore throat.
• CARDIOVASCULAR: Negative for ankle edema, palpitations, chest pain/pressure, or dyspnea on rest or exertion.
• RESPIRATORY: Denies breathing difficulties, cough, shortness of breath, dyspnea, or wheezing.
• GASTROINTESTINAL: Denies nausea/vomiting, heartburn, abdominal pain, flatulence, changes in bowel movement, pain with defecation, or rectal bleeding.
• GENITOURINARY: Denies painful urination, penile discharge, urinary frequency or urgency, or changes in urine color.
• MUSCULOSKELETAL: Reports tenderness and swelling of the right lower leg. Denies joint pain, joint stiffness, or muscle pain.
• INTEGUMENTARY: Reports laceration and erythema on the right lower leg. Denies skin rash, hair loss, or nail discoloration.
• NEUROLOGICAL: Denies generalized weakness, dizziness, tingling sensations, unsteady gait, memory loss, or mood changes.
• PSYCHIATRIC: Denies depression, anxiety, or sleep disturbances.
• ENDOCRINE: Denies heat or cold intolerance, increased urination, excessive thirst, or hunger.
• HEMATOLOGIC/LYMPHATIC: Negative for bruising, delayed wound healing time, or anemia.
• ALLERGIC/IMMUNOLOGIC: Denies hives, allergic rhinitis, or eczema.

Physical Exam:

• GENERAL APPEARANCE: The patient is a 48-year-old well-developed, obese male in no acute He is oriented to person, place, and time. He maintains eye contact and speaks in normal volume and rate.
• VITAL SIGNS: Temp-100.4F; BP-, BP-128/84 (sitting); HR-92; RR-20; SPO2- 99%; Height- 5’5, Weight- 210, BMI-34.9.
• HEENT: Head: Symmetrical and normocephalic. White sclera, Pink conjunctiva, PERRLA. TMs are transparent and shiny. The nose is symmetrical and midline. Nostrils are patent. The tongue is pink and midline. The throat is vascular without swelling, exudates, or lesions.
• NECK: Supple with full ROM. Trachea is
• CHEST: Respirations are smooth with no use of accessory muscles. Uniform chest movements.
• LUNGS: Lungs clear on auscultation.
• HEART: Regular heart rhythm; S1 and S2 present.
• BREASTS: No skin or nipple retractions.
• ABDOMEN: The abdomen is round with no scars. Normoactive bowel sounds in all quadrants. No organomegaly on percussion. The abdomen is soft on palpation with no tenderness or masses.
• GENITOURINARY: Normal male genitalia.
• RECTAL: [Male]. Normal sphincter tone. The prostate is smooth and non-tender.
• EXTREMITIES: Swelling of the posterior part of the right leg.
• NEUROLOGIC: Normal gait and balance. Muscle strength-5/5; CNs- intact.
• PSYCHIATRIC: The patient is awake, alert, and oriented Recent and remote memory is intact. Appropriate mood and affect.
• SKIN: Erythema, tenderness, and warmth on a poorly demarcated posterior part of the right leg. The affected area oozes pus.
• LYMPHATICS: Non-palpable cervical lymph nodes.

Laboratory and Radiology Results:

Complete blood cell (CBC) count- Elevated WBCs

Assessment: (Provide three references)

·         Differential Diagnoses:

1.      Purulent Cellulitis of the Right Lower limb (L03.115):  Cellulitis is a non-necrotizing inflammation of the skin and subcutaneous tissue from a primary infection (Ong et al., 2022). It is the primary diagnosis based on positive findings of pain, swelling, erythema, pus, and warmth over the skin of the right lower leg after blunt trauma. The patient also had mild fever and elevated WBCs, indicating an underlying infection.

2.      Deep venous thrombosis (DVT) (I82. 40): DVT is characterized by coagulated blood or thrombus in a deep venous conduit that transports blood to the heart (Abdelmalik et al., 2023). The patient has positive symptoms of DVT like unilateral leg swelling, pain, warm skin, tenderness, and erythematous skin around the painful leg area.

3.      Necrotizing fasciitis (M72. 6): The patient has erythema, pain, and tenderness of the right lower leg after sustaining a blunt trauma, which is consistent with Necrotizing fasciitis (Chen et al., 2020). However, the patient has no signs of infection of the fascia, making it an unlikely primary diagnosis.

• Acute and Chronic Medical Conditions:

1. Purulent Cellulitis of the Right lower limb
2. Obesity
3. Hyperlipidemia

Treatment Plan: (Provide three references)

Medications: Cephalexin (Keflex) 500 mg PO QID. It is used to treat infections caused by streptococci or penicillinase-producing staphylococci (Ong et al., 2022).

Continue with Atorvastatin 20 mg OD.

Non-pharmacologic interventions:  Surgical incision and drainage of the lesion. The incised part was cleaned and dressed with normal saline and sterile gauze.

Consults: Consulted a surgeon on the incision and drainage of the lesion.

Health Education: The patient was taught to apply warm compresses twice a day to areas of cellulitis to increase comfort (Sullivan & de Barra, 2018).

Discharge Plan: Discharge on Keflex 500 mg PO QID; Schedule a follow-up after two weeks.

Geriatric Considerations:

Age alone does not affect treatment principles for bacterial cellulitis, including prescribing antibiotics. Nonetheless, age-related pharmacokinetics and pharmacodynamics, a patient’s cognitive status, and social circumstances can influence treatment decisions especially the need for hospitalization. Aging is significantly associated with increased mortality from cellulitis (Kumar et al., 2019). Therefore, if this patient was a geriatric (above 65 years), caution would be taken to avoid delaying antibiotic treatment to mitigate the risk of morbidity and mortality.  Hospitalization would have been a priority for the older patient and the patient’s comorbidities would have been managed during hospitalization since they increase the risk for morbidity (Kumar et al., 2019).

 References

Abdelmalik, B. H. A., Leslom, M. M. A., Gameraddin, M., Alshammari, Q. T., Hussien, R., Alyami, M. H., Salih, M., Yousef, M., & Yousif, E. (2023). Assessment of Lower Limb Deep Vein Thrombosis: Characterization and Associated Risk Factors Using Triplex Doppler Imaging. Vascular health and risk management, 19, 279–287. https://doi.org/10.2147/VHRM.S409253

Chen, L. L., Fasolka, B., & Treacy, C. (2020). Necrotizing fasciitis: A comprehensive review. Nursing, 50(9), 34–40. https://doi.org/10.1097/01.NURSE.0000694752.85118.62

Kumar, M., Jong Ngian, V. J., Yeong, C., Keighley, C., Van Nguyen, H., & Ong, B. S. (2019). Cellulitis in older people over 75 years – are there differences?. Annals of Medicine and Surgery (2012), 49, 37–40. https://doi.org/10.1016/j.amsu.2019.11.012

Ong, B. S., Dotel, R., & Ngian, V. J. J. (2022). Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis?. International Journal of general medicine, 15, 6561–6572. https://doi.org/10.2147/IJGM.S326459

Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical medicine (London, England), 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160