Soap note
SUBJECTIVE: Patient is here for followup of a left lower leg (1)__________ phlebitis. She was placed on aspirin therapy and an (2)__________ wrap at that time. The patient states that she has a long history of (3)__________ veins, which are painful, especially after standing for prolonged periods. She is inquiring as to whether or not she is a surgical candidate for this. Patient denies any chest pains, shortness of breath. She denies any warmth to the area and states that the acute tenderness she had over the (4) __________ is now resolved. The patient also has some TED hose with her today, which she wanted to see if the size is appropriate for her.
OBJECTIVE: Lower extremities: The left lower leg on the upper medial portion of the calf extending above the knee has significant varicose veins, which are very (5) __________. These are not painful to touch. There is no warmth or (6) __________associated with this. There is no (7) __________ firmness or clot noted. There are standard varicosities of both lower extremities, some of lesser and some of equal degree. The patient’s (8) __________ hose were placed on her and are the appropriate size for her.
ASSESSMENT/PLAN: Left lower extremity (9) __________, which are symptomatic and significant enough for surgical evaluation and, most likely, surgical treatment. The patient will continue with her (10) __________ therapy as previously directed. She may wear the TED hose and is referred to Surgery for definitive evaluation and treatment. Patient agrees with plan.
1. superficial
2. Ace
3. varicose
4. phlebitis
5. tortuous
6. erythema
7. palpable
8. TED
9. varicosities
10. aspirin
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