Soap note

Question

SUBJECTIVE: The patient is here for followup from the emergency room. She had swelling of her large toe with purple discoloration and progressive pain, which started 3 days ago. She went to the emergency room and was thought to have (1)________. An x-ray was done and was normal. ESR was 60, and a (2)________ was 7.6. The patient was placed on Vioxx, as well as some Percocet, according to patient. She has not taken the (3)________. She has taken the Vioxx 12.5 mg b.i.d. She has had some decreased tenderness and decrease in the discoloration. The toe is still quite painful. The patient is otherwise without any complaints. She states that she is tolerating the Vioxx, with only minimal GI distress. Patient has difficulty taking (4)________.

OBJECTIVE: Extremities: Right large toe has tenderness, with mild (5)________ and some mild purplish discoloration. There is no (6)________. Neurovascular is otherwise intact.

ASSESSMENT/PLAN: Resolving (7)________ arthritic attack. Continue with Vioxx 12.5 mg b.i.d. until pain free. Patient may increase to 25 mg b.i.d. if her stomach tolerates this. She is to not use the foot as much as possible and limit all (8)________. She may use warm moist soaks. Will recheck (9)________ today and reevaluate in 1 week and (10)________. Patient agrees with plan. The patient will return to work in 1 week. Work note given.

Answer 1

1. gout
2. uric acid
3. Percocet
4. antiinflammatories
5. edema
6. crepitus
7. gouty
8. weightbearing
9. ESR
10. p.r.n.