SOAP note 1
Identifying Data:
Name: NM
Age: 33 years old
Race: Hispanic
Date & Time: 3/08/2021 1:00PM, follow up on 3/09 post-op
Location: Metropolitan Hospital Center
Source of Referral: internal medicine
Source of Information: Self
Mode of Transport: personal automobile
S:
33 year old male patient with a past medical history of an appendectomy presents to the ED on 2/8 complaining of sharp intermittent abdominal pain, located in the right epigastric area. He described the pain as colicky and sharp, that lasted anywhere from 2 minutes to 1 hour. He says the pain also radiated to his right shoulder. He denies eating fatty foods, or eating anything different. He denies any nausea, vomiting, diarrhea, constipation or changes to his urine. He says he never had this type of pain before. In the ED he had an ultrasound of his gallbladder done which showed multiple mobile stones. He was then scheduled to have a cholecystectomy done by the surgery department on 3/8.
On 3/8 the patient underwent a laparoscopic cholecystectomy under generalized anesthesia for symptomatic cholelithiasis. The gallbladder was dissected via electrocautery and the stones were removed and placed in specimen bags.
The patient was followed up on 3/9, and seemed to be in no acute distress. There were no acute events overnight, and the pain is well controlled. The patient is tolerating a regular PO diet, but is not passing any flatus and has not had a bowel movement since the procedure. He denies any fevers, chills, nausea, vomiting, headache. He is currently on acetaminophen 975mg q6 hours, omeprazole 40mg every morning, and ondansetron and oxycodone as needed.
PMHx:
- Appendicitis 6 years ago ONLY chornic issues
PSHx:
- Appendectomy in 2015, no complications
- Denies any blood transfusions
Allergies:
- Denies any allergies to food or drugs
Medications:
- Patient does not take any medications regularly
FHx:
Mother: alive and well
Father: alive and well
Social:
Denies every smoking cigarettes, alcohol use, or illicit drug use
Patient states she eats a healthy balanced diet, and exercises 3 times a week.
Patient is sexually active with girlfriend, no history of STIs.
O:
Vitals:
Temperature: 98.5F, oral
HR: 63 bpm, regular
BP: 136/79
RR: 18, nonlabored
SpO2: 98%, room air
Physical Exam post-op:
BE MORE CONCISE
General:
33 year old female in no acute distress. Alert and Oriented x 3. Patient is well developed and has proper hygiene and dressing. NAD, Alert and oriented x 3
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Abdominal:
Soft, nondistended, non tender to palpation. Laparoscopic scar is healing well.
Skin:
Abdominal incision sites are covered with dressing and the supraumbilical area is moderately saturated
Wounds: clean dry and intact
Labs:
138 | 100 | 11
———————-< 109
4.1 | 27 | 0.9
I & Os:
I – 125 ml oral intake
O – 600ml
Total: -475ml
Procedure: laparoscopic cholecystectomy under generalized anesthesia-no complications, well tolerated
A:
33 year old male POD 1 s/p lap chole. Pain well controlled, tolerating a diet , wounds clean dry and intact
P:
acute cholecystitis:
Tylenol 975 q6 hours
Oxycodone 5 for pain PRN
Maintain regular diet and level of food tolerated
Ambulate as tolerated
No antibiotics at this time->unless symptoms worsen or if there is signs of infections
Monitor for return of bowel function
f/u labs to assess for infection
Discharge today if labs are normal
SOAP note 2
Identifying Data: make changes
Name: HB
Age: 43 years old
Race: African American
Date & Time: 3/11/2021 9:00AM , follow up on 3/12 at 7AM
Location: Metropolitan Hospital Center
Source of Referral: ED
Source of Information: Self
Mode of Transport: personal automobile
S:
HB is a 43 year old male with a significant past medical history of Crohn’s disease (diagnosed in the 1990s), presents to the ED on 3/11 complaining of intermittent epigastric and umbilical pain for 3 days. He says the pain started randomly, with no enticing event. He characterizes the pain as a sharp cramping pain, that is non radiating. He rates the pain as a 6/10 at its worst. Nothing alleviates or exacerbates the pain. The pain is not associated with his eating, and he has had no change in his bowel habits. His last bowel movement was one day ago. He states that he is on Sulfasalazine for his crohns, but is not always compliant with it. He denies any nausea, vomiting, blood in his stool, changes in stool color, diarrhea, constipation, or any fevers or chills. In the ED, a CBC, CMP, BMP, LFT, and lipase was done, with no significant findings aside from mild anemia. A CTA of the abdomen was also done, which showed a dilated bowel. He received Zosyn, metronidazole, and IV fluids and was sent to the medicine unit for observation.
He also had a secondary complaint of bilateral lower extremity pain for 1 week. He denies any trauma or any enticing event. The pain is constant, and non-radiating. He rates the pain as a 7/10. On exam the Distal pulses and sensations were intact, and patient had full range of motion. A troponin was ordered which was negative. A Lower extremity doppler was also done which showed no signs of a DVT.
PMHx:
- Crohn’s Disease (diagnosed in the early 1990s)
PSHx:
- Patient denies past surgeries, injuries, or blood transfusions
Allergies:
- Allergic to Bactrim: gets a rash
- No food or season allergies.
Medications:
- Sulfasalazine 1000mg q8 hours every day
- Patient is not always compliant
FHx:
Mother: alive and well
Father: alive and well
Social:
- Patient denies smoking, ilicit drug use, or drinking alcohol
- Has a balanced diet of meats and veges and exercises 2x a week
- Is sexually active with spouse, denies any history of STD
O:
Vitals:
Temperature: 98.4F, oral
HR: 78 bpm, regular
BP: 100/48
RR: 18, nonlabored
SpO2: 100%, room air
Physical Exam:
General:
43 year old man, unkempt appearance in mild distress. Appears appropriate for his age
ENT:
Clear discharge form both R and L eyes, otherwise unremarkable. No redness or visual changes
Skin:
Warm and well-perfused throughout. Skin without cyanosis or jaundice. Capillary refill < 2 seconds throughout.
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Abdomen:
Positive diffuse abdominal tenderness to palpation, no guarding or rebound. Abdomen flat and non-distended. BS present in all 4 quadrants.
Msk:
R and L ankle swelling and 2 cm long laceration to ankles with tenderness to palpation. DP pulses intact. FROM
Feet:
Long thick toenails in bilateral feet, possible fungal disease
Labs:
140 | 107 | 18
———————-< 124
4.0 | 25 | 0.9
HGB: 8.6, HCT: 27.8
I & Os:
I – 300 ml oral intake
O – did not receive updated output
Imaging:
CTA abdomen with IV contrast: dilated small bowel in LLQ with thickened folds
LE Doppler: No DVT
A:
43 year old male with a PMH of Crohn’s, previously on sulfasalazine presents with abdominal pain for 3 days and bilateral LE extremity pain for 1 week. History and exam is consistent with Inflammatory bowel disease and LE cellulitis and mild anemia based on HGB results.
P:
IBD: Fecal occult blood test
Pepcid trail- monitor if symptoms resolve
Zofran for nausea
GI Consult for futher workup and evaluation
Cellulitis: clean and dress
Zosyn 3g q6h for infection control
Tylenol PRN for pain
Anemia: trend CBCs – follow up with PCP
SOAP note 3
Identifying Data:
Name: OP
Age: 31 years old
Race: Caucasian
Date & Time: 3/10/2021 11:30AM
Location: Metropolitan Hospital Center
Source of Referral: internal medicine
Source of Information: Self
Mode of Transport: personal automobile
S:
OP is a 31 year old male with a significant past medical history of chronic hepatitis C, polysubstance abuse, and asthma comes in to the ED complaining of yellowing of the skin for 3 days. He also had right upper quadrant pain, and 2 episodes of nausea and vomiting. He describes the abdominal pain as a constant dull pain that was not radiating. He rates the pain as a 4/10. He had 2 episodes of vomiting, non bloody and non bilious. He says he had 2 bowel movements in 5 days, which is less than his normal amount. Nothing exacerbates or alleviates the symptoms. He also noticed some changes in stool color. He also complains of dark urine, light stool color, increased sweating and constipation. He denies any fevers, chest pain or shortness of breath. In the ED he was also requesting a STI and HIV test.
He is admitted to medicine for RUQ pain, jaundice, and nausea and vomiting for observation.
PMHx:
- Chronic hepatitis C
- Polysubstance abuse
- Asthma- well controlled
PSHx:
- Inguinal hernia repair when he was 9 years old
Allergies:
- Denies allergies to food or medications
Medications:
- Albuterol PRN: last used was 5 months ago
FHx:
Father: heart attack, alive and well
Mother: no diseases, alive and well
Grandmother: deceased at 75 of liver cancer
Social:
- Denies smoking cigarettes
- Admits to cocaine and heroin use, consistently since he was 25 years old.
- Admits to social alcohol use on the weekends
- Sexually active with partner, no history of STDs
O:
Vitals:
Temperature: 98.6F, oral
HR: 85 bpm, regular
BP: 125/86
RR: 18, nonlabored
SpO2: 100%, room air
Physical Exam:
General:
31 year old man, unkempt appearance in no acute distress. Appears appropriate for his age. Alert and oriented x 3
ENT:
Eyes EOMI, PERRLA, no acute trauma or visual changes. Oral mucosa moist and hydrated.
Skin:
One 1cm by 0.5 cm erythematous lesion on the dorsolateral aspect of the right wrist, otherwise normal.Warm and well-perfused throughout. Skin without cyanosis or jaundice. Capillary refill < 2 seconds throughout.
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Abdomen:
Positive hepatomegaly on exam. Soft and non distended. Non tender and no rebound or guarding. BS present in all 4 quadrants.
Msk:
No tenderness or lesions. FROM. DP intact.
Labs:
130 | 94 | 14
———————-< 119
3.9 | 26 | 1
Total bili: 9.2
Direct: 7.3
ALK: 206
AST/ALT: 358/1349
PT/INR/PTT: normal
Imaging:
GB US: large spleen, otherwise normal
A:
31 year old male presents to the ED with signs of jaundice, RUQ pain, N/V and constipation for 3 days. On exam there is positive hepatomegaly, and labs show elevated bilirubin and ALK, AST. History and exam is consistent with chronic hepatitis C and drug.
P:
Chronic hepatitis:
Monitor vitals
Most often resolves on its own; monitor for symptom changes
Limit use of alcohol
If symptoms persist, may consider the addition of antiviral medications
Surgery is not warranted at this time.
Repeat blood work
Drug withdrawals:
Monitor signs for drug withdrawal (nausea, tremors, agitation, sweating)
Utox, PCP, THC and amphetamine levels (to check levels in the body)
SOAP note 4
Identifying Data:
Name: AS
Age: 49 years old
Race: Hispanic
Date & Time: 3/9/2021 7:00AM
Location: Metropolitan Hospital Center
Source of Referral: ED
Source of Information: Self
Mode of Transport: personal automobile
S:
AS is a 49 year old Spanish speaking female with no significant past medical history who presents to the ED with intermittent abdominal pain that started 1 week ago. She states the pain is in her suprapubic area and that it is non radiating and crampy in nature. The pain comes and goes at random times and there was no enticing event that started it. She says the pain has no relation with food, and that her diet has not changed from her normal balanced diet of meats and vegetables. She rates the pain as a 7/10 at its worst. Nothing alleviates or exacerbates her symptoms. She has not taken any medications for this, and states this has never happened to her before. She had one normal bowel movement a day ago, and says she normally has one bowel movement a day. She is still tolerating food, has been having no pain with urination, and is having no changes in her stool. She denies any fevers, chills, nausea, vomiting, diarrhea, constipation, urinary changes, shortness of breath or chest pain. She also denies any recent travel or sick contacts. Patient is admitted to surgery for observation
On 3/10, the patient was followed up for the surgery team, and she had no acute distress over night, no worsening of her pain or symptoms. She tolerated the NPO order, and has had no flatus and had no bowel movements.
PMHx:
Patient denies any past medical history
PSHx:
Patient denies past surgeries, injuries, or blood transfusions
Allergies:
Allergic to peanuts
-no known drug allergies
Medications:
- Patient only takes a daily multivitamin
FHx:
Mother: alive and well
Father: alive and well
Social:
- AS denies ever smoking or using illicit drugs
- Admits to occasional alcohol use on the weekends-unable to quantify
- Is sexually active with partner, denies ever being diagnosed with STD
O:
Vitals:
Temperature: 98.4F, oral
HR: 100 bpm, regular
BP: 110/90
RR: 18, nonlabored
SpO2: 98%, room air
Physical Exam:
General:
49 year old female alert and oriented x 3, in no acute distress. Appropriately dressed and well groomed.
ENT:
EOMI, PERRLA, no visual changes or discharge
Skin:
Warm and well-perfused throughout. Skin without cyanosis or jaundice. Capillary refill < 2 seconds throughout.
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Abdomen:
Mildly tender to palpation to suprapubic region, no rebound or guarding. Abdomen flat and non-distended. BS present in all 4 quadrants.
Msk:
No tenderness or redness. DP pulses intact. FROM
Labs:
138 | 102 | 11
———————-< 125
3.8 | 26 | 0.6
WBC:17, HCT: 36
I & Os:
I – 175ml NS
O – 500 ml
———-total: -325 ml
Imaging:
CT abdomen and pelvis: diverticulosis with wall thickening and fat stranding
A:
49 year old female with no past medical history comes in complaining of one week of suprapubic abdominal pain. History and physical exam is consistent with diverticulitis
P:
Diverticulitis:
Admit to surgery for observation
No acute surgical intervention at this time; treat with antibiotics
IV Zosyn
NPO/LR @125 ml for rehydration
Monitor ins and outs
Ambulate and assess pain symptoms
Pain control
f/u labs to see if the antibiotics have controlled the infection
SOAP note 5
Identifying Data:
Name: BG
Age: 62 years old
Gender: male
Date & Time: 3/10/2021 8:00am
S:
BG is a 62 year old male with a significant past medical history of Diabetes, HTN, and GERD, who presents to the clinic for abdominal pain for 1 month. Patient was seen by internal medicine for generalized abdominal pain that was intermittent for 1 month, described as a dull ache. He denies any nausea, vomiting, diarrhea, constipation, fevers or chills. He denies any sick contacts or On exam by his physician he was found to have generalized lymphadenopathy. He also had an interventional radiology biopsy done that showed that he had non-Hodgkins lymphoma. Patient is sent to the surgery clinic for a chemo-port placement for his upcoming chemotherapy. He has no complaints at this time.
PMHx:
- Diabetes type 2
- HTN
- GERD
PSHx:
Colonoscopy on 3/3/21-no complications
EGD biopsy- 3/3/21, no complications
Cholecystectomy- in 2012, no complications
Allergies:
Denies any allergies to food or drugs
Medications:
- Dextrose
- Docusate
- Glucagon
- Insulin
- Lisinopril
- omeprazole
- Patient says that he is compliant with all of them
FHx:
Mother: history of breast cancer, deceased at 68
Father: alive and well
Brother: deceased of stomach cancer at the age of 56
Social:
Denies every smoking cigarettes, alcohol use, or ilicit drug use
Patient states she eats a healthy balanced diet, and exercises 3 times a week.
O:
Vitals:
Temperature: 98.4F, oral
HR: 96 bpm, regular
BP: 131/77
RR: 18, nonlabored
SpO2: 100%, room air
Physical Exam:
General:
62 year old female in no acute distress. Alert and Oriented x 3. Patient is well developed and has proper hygene and dressing.
Neck:
Supple, full range of motion, no masses or lesions.
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Abdominal:
Soft, nondistended. No tenderness to palpation, no rebound or guarding. No hepatosplenomegaly noted
Labs:
HCT: 34.9 (H)
HBG: 11.5 (H)
PLT: 129 (H)
INR: 1.2
Imaging:
IR Biopsy: positive for Non-hodgkins-lymphoma
A:
62 year old male presents with a past medical history of Diabetes, HTN, and GERD presents with generalized abdominal pain and generalized lymphadenopathy for 1 moth. History and imaging is consistent with Non-Hodgkins Lymphoma. Admit patient for a chemoport placement
P:
Admit to Surgery for a Chemo-port placement
Pain control
Trend pre-op labs (T & S, PT INR, PTT)
SOAP note 6
Identifying Data:
Name: PL
Age: 40 years old
Gender: female
Date & Time: 3/23/2021 7:30AM
S:
PL is a 40 year old female with no significant medical history who comes in to the ED for a sharp intermittent left sided headache for 4 days. She says the headache was gradual in onset and characterizes it as a throbbing and pressure like in nature. She rates the headache as a 7/10, at its peak. She says nothing makes the pain worse or better. She is also having numbness in the left upper extremity, left sided chest pain, and left sided neck pain that is aggravated by movement. She has no history of recurrent headaches in the past, or any history of strokes or TIAs. She denies any seizures, vomiting, weakness, dysphagia, loss of consciousness, dizziness, fevers, chills, or shortness of breath. Patient is stressed and anxious as her friend recently passed due to a stroke.
She is admitted to surgery for further workup and testing.
PMHx:
- Cervical CA- resolved
PSHx:
- Abdominoplasty- date unknown, no complications
- CIN 2 cervical biopsy- date unknown, no complications
- C-section: 2009, no complications
Allergies:
- Denies any allergies to food or drugs
Medications:
- Patient denies taking any medications, besides a daily multivitamin
FHx:
- Father: HLD, alive and well
Social:
Denies every smoking cigarettes, alcohol use, or illicit drug use
O:
Vitals:
Temperature: 98.3F, oral
HR: 69 bpm, regular
BP: 104/59
RR: 17, nonlabored
SpO2: 98%, room air
Physical Exam:
General:
40 year old female in no acute distress. Alert and Oriented x 3. Patient is well developed and has proper hygiene and dressing.
Neck:
Supple, full range of motion
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Extremities:
FROM in upper and lower extremities, no lesions or tenderness. DP pulses intact
Neuro:
Normal mental status exam, Cranial nerves 1-12 intact, 5/5 motor and sensory systems intact in UE and LE bilaterally. Gait unremarkable. Kernig and Brudzinski sign negative.
Labs:
140 | 103 | 12
———————-< 107
3.9 | 25 | 0.5
Protein: 6.5
Neutrophil: 65.6
Creatine: 0.6
Troponin: <0.01
Imaging:
CT angio head with and without contrast: 1 enhancing 1.3cm dural based mass in the right CP angle cistern, consistent with a meningioma
CT neck: left vertebral artery dissection
Chest xray: unremarkable
A:
40 year old female comes in with 4 days of a left sided headache, associated with left sided upper extremity weakness, left sided neck pain and left sided chest pain. History and imagining finding is consistent with a diagnosis of a meningioma, and a left vertebral artery dissection
P:
Telemetry
Observation with neuro checks q 4 hours
Monitor vitals
Neuro consult, vascular consult
Antiplatelet therapy
Aspirin 81mg
Normal saline infusion
Acetaminophen
Obtain an MRI of the brain and MRA of the neck
SOAP note 7
Identifying Data:
Name: CD
Age: 52 years old
Gender: female
Date & Time: 3/8/2021 12:00PM, follow up on 3/9 post-op
S:
CD is a 52 year old female patient with a significant past medical history of thyroid cancer, s/p total thryoidectomy in March 2019, cervical lymphadenopathy, HLD, and hypothyroidism who comes into the general surgery clinic for a follow up of a Fine needle biopsy that was done on 2/9/21. In the referral note, it was stated that the patient has been having intermittent coughing up of blood since the thyroidectomy, and has recently worsened. She denies any fevers, chills, nausea, vomiting, or soreness of the neck. Radioactive iodine were done on 3/8, which showed abnormal activity in the neck. FNA pathology results was negative for malignant cells. Patient is admitted to the general surgery department and is scheduled for an excisional biopsy with possible dissection.
On 3/9/21 the patient underwent a left neck dissection of levels 1-4. Patient tolerated the procedure well. The patient had scant output from the drain overnight. The drain was removed on post-op day 1, and patient was cleared for discharge.
PMHx:
- Papillary Thyroid cancer
- Lymphadenopathy
- Neuropathy
- Diabetes type 2
- GERD
- HLD
- Granulomatosis
- Hypothyroid colitis
PSHx:
- Thyroidectomy in 3/2019- no complications
- FNA- no complications
- Hysterectomy- date unknown, no complications
- Esophagastruduosecopy- date unknown, no complications
Allergies:
Denies any allergies to food or drugs
Medications:
- Atorvastatin
- Ergocalciferol
- Omeprazol
- Famotadine
- Gabapentin
- Levothyroixine
- Metformin
- Patient d says that she is compliant with all medications
Social:
Denies every smoking ciragettes, alcohol use, or ilicit drug use
O:
Vitals:
Temperature: 98.4F, oral
HR: 67 bpm, regular
BP: 120/66
RR: 20, nonlabored
SpO2: 97%, room air
Physical Exam:
General:
52 year old female in no acute distress. Alert and Oriented x 3. Patient is well developed and has proper hygiene and dressing.
ENT:
Moist mucosal membranes, no lesions or exudates. Eyes: EOMI, no visual changes
Neck:
Healing inscision, no drainage. Supple, full range of motion, no masses or lesions, no lymphadenopathy
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Labs:
142 | 103 | 11
———————-< 113
3.5 | 25 | 0.68
HGB: 8.6, HCT: 27.8
I & Os:
I – 750 ml oral intake
O – did not receive updated output
Imaging:
FNA 2/9: negative for malignant cells
PET on 3/8: cervical lymphadenopathy
Procedure: left modified radial neck dissection under general anesthesia
- Patient tolerated the procedure well. Had a drain left over night with scant discharge. Patient deemed clear for discharge.
A:
52 year old female POD 1 s/p modified radical neck dissection for cervical lymphadenopathy. She has a history of papillary thyroid cancer with a total thyroidectomy.
P:
Pain control with analgesics
Continue regular diet and activity
Patient instructed to shower 48 hours after surgery
Follow up in 1 week post-op
SOAP note 8
Identifying Data:
Name: CL
Age: 81 years old
Gender: Female
Date & Time: 3/17/2021 9:00AM
S:
CL is a 81 year old female patient with a PMHx for hypothyroidism comes in for a for an infection on her third right digit. She said this was here for almost a year, and has rejected previous surgical interventions. She has been treated with antibiotics and anti-fungals in the past, with no resolution in her symptoms. She says she changes the dressing 2x a day and washes around it with water. She has pain at the finger tip to tough and pain with movement, rating it a 8/10 at its worst. She states the lesion looked like a pimple when she first noticed it a year ago, and has continued to grow. She denies any nausea, vomiting, fever, chills, chest pain, or lesions any where else on her body. She was originally seen on 2/28 and had a debridement and biopsy scheduled for 3/1. The pathology reports stated that the lesion is an ulcerated infiltrating malignant melanoma.
Patient was then scheduled for an amputation on 3/15, which the patient tolerated well with no complications.
PMHx:
- Hypothyroidism diagnosed about 15 years ago (patient unsure of exact date)
PSHx:
- Right cataract extraction in 2011
- Patient denies past surgeries, injuries, or blood transfusions
Allergies:
- Allergic to penicillin and shrimp- hives
Medications:
- Levothyroxine 125mcg daily
FHx:
- Mother: deceased at 82
- Father: hypertension, deceased at 78
Social:
- Patient denies smoking, ilicit drug use, or drinking alcohol
O:
Vitals:
Temperature: 98.7F, oral
HR: 80 bpm, regular
BP: 135/86
RR: 18, nonlabored
SpO2: 98%, room air
Physical Exam:
General:
Mildly anxious, no acute distress. Alert and Oriented x 3
Lungs:
Lungs clear to auscultation bilaterally without adventitious lung sounds.
Heart:
No visible abnormal pulsations or heaves. RRR; S1 and S2 present without murmurs, rubs, or callops.
Skin/Hand:
Right: middle finger with gangrenous eschar without abscess or redness. Ulceration was 5cm by 4 cm growth fungated mass. Pink/purple discoloration more proximally to the distal third of the middle phalanx. Able to flex and extend minimally at the DIP. Flexion and extension is intact at the PIP/MCP. No sensation at the right middle digit finger tip.
Left: unremarkable findings
Labs:
No labs were ordered for this patient
Imaging:
Tissue culture: positive for pseudomonas aeruginosa and cornybacterium
Pathology report of tissue biopsy: infiltrating malignant melanoma, ulcerated
A:
81-year-old female s/p right third digit DIP amputation due to a infiltrating malignant melanoma with ulcerated gangrenous mass. Patient tolerated the procedure well with no complications
P:
Infiltrating malignant melanoma of finger s/p amputation:
- Patient discharged home
- -follow up pathology
- Discharge medications: Tylenol and ibuprofen as needed
- Diet and activity as tolerated
- Wound care: keep wound clean and dry, OK to shower after 48 hours. Keep dressing dry, no immersion in water for 3-4 weeks or until cleared by surgeon. Do not remove dressing for 1 week until follow up with surgeon
- Have patient follow up with hand/plastics clinic in one week
