Summary Tina Jones health exam-SOAP Note with Latest Solution Provided( Musculoskeletal, Gastrointestinal and Skin Review)

Chief Complaint - ANSWER Scrape on foot. It is infected and causing pain(7 out of 10). - ANSWER Right foot pain, fever, nausea - ANSWER History of Present Illness - ANSWER A week ago the scrape startedand the pain got a lot worse in last few days. - ANSWER Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. She is a good historian. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. The injury occurred about one week ago. Her pain has worsened, and the swelling has persisted. She tried ibuprofen, but it didn't work well. The foot feels better when she rests, and it hurts more when she walks on it. Her pain is a 9 when she tries to ambulate. She took her temperature at home and reports it was 102. She has not been eating much and has been staying in bed the last few days, per patient report. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. She reports diarrhea overnight. Pain improved with oxycodone. Stomach upset. - ANSWER Pain Assessment - ANSWER 6/7 out of 10 - ANSWER Pain is rated as 7. Pain is localized to ball of foot related to wound. Dull and constant ache. Patient has tried ibuprofen, but reports it does not work well. Patient states there is relief when foot is elevated, not walking on it. Patient answers questions clearly and consistently. Offers information without hesitation. Vital signs are within range. - ANSWER Allergies - ANSWER Allergic to penicillin, and also allergic to cats. - ANSWER • Penicillin: rash - ANSWER • Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation - ANSWER