The patient is a 68-year-old female presenting with left hand and forearm pain and swelling for approximately one month.
ASSESSMENT: Primary diagnosis provided ICD-10 code. The plan was supported with 1-2 reference(s) and provided at least 2-3 differential diagnosis with rationales with ICD-10 codes in APA format. A reflection note provided.
PLAN: A pertinent plan of care, follow-up instructions, and patient education was developed and supported with at least one to two references in APA format.
SOURCES( please provide pertinent sources.) No Limit.
USE the Soap Template attached for reference
SOAP
CC
LEFT FOREARM AND HAND SWOLLEN. RIGHT FOOT IN PAIN AFTER FALL
Subjective
The patient is a 68-year-old female presenting with left hand and forearm pain and swelling for approximately one month. She denies any known trauma to the affected area. The patient also reports a fall approximately two weeks ago after stepping on toys, resulting in bruising and mild pain of the right foot and right ankle. She states that both the pain and swelling have been gradually improving. The patient reports she was evaluated in the emergency department at the time of the fall, where X-rays were obtained and she was informed that no fractures were identified.
The patient denies head injury, loss of consciousness, dizziness, or other associated symptoms. She denies any additional complaints at today’s visit.
The patient reports she is currently being followed by Dr. Alireza K. Nazemi, orthopedist, for right hand, right elbow, and bilateral knee pain. She states she was advised that her symptoms may be rheumatologic rather than orthopedic in nature and was referred to Dr. Aelita Khachatrian, MD, rheumatologist. The patient reports she has the referral but has not yet scheduled an appointment.
The patient reports she has not been evaluated by nephrology, ophthalmology, or podiatry and does not currently have referrals to these specialties.
Medications
Vitamin D3 50 mcg (2,000 unit) capsule
Fosamax 70 mg tablet, TAKE 1 TAB PO QWEEKLY
atorvastatin 20 mg tablet
pioglitazone 15 mg tablet
glipiZIDE 10 mg tablet
acarbose 25 mg tablet
Jardiance 25 mg tablet
NIFEdipine ER 60 mg tablet,extended release
lisinopriL 20 mg tablet
clopidogreL 75 mg tablet
Janumet 50 mg-1,000 mg tablet
Allergies
No allergy history has been documented for this patient.
Mental/Functional
Mental Status:
The patient is alert and oriented to person, place, time, and situation. Speech is clear and coherent. Thought processes are logical and goal directed. Mood and affect are appropriate. No acute cognitive deficits noted.
Functional Status:
The patient is ambulatory and able to perform activities of daily living independently. She reports mild functional limitation related to left hand and forearm pain but remains able to complete routine self-care activities. Gait is steady. No functional deficits noted following the reported fall.
Vitals
BP:
138.0 / 56.0
HR:
92.0 bpm
RR:
13.0 rpm
Temp:
98.3 °F
Ht/Lt:
5′ 0″
Wt:
114 lbs 6 oz
BMI:
22.34
SpO2:
99.0%
Comments: PATIENT IS HERE DUE TO HAVING H AR AND HAND SWOLLEN AND HER RIGHT FOOT IS IN PAIN AFTER FALL. P/L: 05/10.
Objective
GENERAL:
The patient appears in no acute distress (NAD). She is cooperative with the examination, well groomed, well developed, well nourished, and overweight.
HEENT:
Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation (PERRLA).
NECK:
Neck is soft and nontender with full range of motion.
RESPIRATORY:
No respiratory distress noted. Lungs are clear to auscultation bilaterally with good air movement. No wheezes, rales, or rhonchi.
CARDIOVASCULAR:
Regular rate and rhythm (RRR). No murmurs, rubs, or gallops appreciated.
EXTREMITIES:
No cyanosis, clubbing, or edema noted in the lower extremities. Left forearm and left hand with visible mild swelling and mild tenderness, including discomfort of the fingers. Distal radial pulses are intact and symmetric bilaterally. Capillary refill is normal.
MUSCULOSKELETAL:
Muscle strength is normal throughout. Right foot/toes and right ankle with residual ecchymosis and mild tenderness to palpation, consistent with reported recent fall. No deformity noted. Range of motion is preserved.
NEUROLOGICAL:
Sensation grossly intact. Gait and station are normal.
PSYCHIATRIC:
The patient is alert and oriented to person, place, and time. Mood and affect are appropriate.
Assessment
Edema of the upper extremity (R60.0) Localized edema
Chronic kidney disease stage 3A (N18.31) Chronic kidney disease, stage 3a
Postmenopausal osteoporosis (M81.0) Age-related osteoporosis w/o current pathological fracture
Hyperlipidemia (E78.5) Hyperlipidemia, unspecified
Diabetes mellitus without complication (E11.9) Type 2 diabetes mellitus without complications
Increased blood pressure (I10) Essential (primary) hypertension
Plan
Laboratory Orders:
Annual labs, including D-dimer.
Referrals:
Nephrology for CKD management (eGFR 53.2, Stage 3a).
Ophthalmology and podiatry for diabetic preventative care.
Rheumatology: Patient advised to schedule an appointment for evaluation of multiple joint pain.
Imaging:
Venous and arterial ultrasound of the left arm to assess swelling.
Patient Education / Safety:
Advised the patient to seek emergency care immediately if there is worsening swelling, changes in color or temperature of the limb, shortness of breath, or chest pain.
Follow-Up: Return to clinic in 2–3 weeks or sooner if needed.
Edema of the upper extremity
Monitor for changes in swelling, redness, warmth, or pain, and report promptly.
Elevate the affected arm when possible to help reduce swelling.
Avoid tight clothing or restrictive jewelry on the affected limb.
Chronic kidney disease stage 3A
Maintain blood pressure and blood sugar within target ranges to slow progression.
Avoid nephrotoxic medications (e.g., NSAIDs) unless directed by your provider.
Attend regular lab follow-ups to monitor kidney function (eGFR, creatinine, electrolytes).
Postmenopausal osteoporosis
Ensure adequate calcium and vitamin D intake through diet and/or supplements.
Engage in weight-bearing and resistance exercises to maintain bone strength.
Discuss fall prevention strategies and follow up with bone density testing as recommended.
Hyperlipidemia
Follow a heart-healthy diet low in saturated fats and cholesterol.
Engage in regular physical activity to help lower cholesterol.
Take medications as prescribed and attend routine labs to monitor lipid levels.
Diabetes mellitus without complication
Monitor blood glucose regularly and follow prescribed diet, exercise, and medication plan.
Attend routine diabetes checkups, including foot exams, eye exams, and labs (HbA1c).
Report any signs of high or low blood sugar promptly (e.g., dizziness, sweating, blurred vision).
Increased blood pressure
Take blood pressure medications exactly as prescribed; do not skip doses.
Limit salt intake, maintain a healthy weight, and exercise regularly.
Monitor blood pressure at home and report readings outside the target range to your provider.
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
