Cellulitis SOAP Notes Homework

Cellulitis SOAP Notes

A patient presents in Urgent Care with concerns about her right lower leg. The patient is a Hispanic, older female (67 years old) who is allergic to PCN, has a very meager income, and shares that she had a bug bite on her leg and after a couple of days, that area of her skin feels hot and slightly tender. What questions might you ask? What treatment would you prescribe? Follow up? Please provide this information with your SOAP note , along with your reference.

Sample Paper

What questions might you ask?

Some of the questions that should be asked during patient examination include what kind of a bug bites the patient; this will help identify the possibility of poisoning, causing the skin to be tender and hot. In case the patient is unaware, she should be asked to tell where she encountered the bug. The patient should be asked whether she is experiencing. Since the bite, the care provider should ask if the patient has taken any medications. If yes, she should provide the details, for example, if the medication was just a pain killer. The patient should be asked about her health history, including diagnosis of any chronic conditions or current illnesses (Meyer et al., 2022).

The patient should also provide details on whether she is taking any prescribed medication currently, and if she is, the care provider should seek to know the kind of prescriptions and for what purposes. Information concerning the health history and current medication is important in determining the type of medication to be prescribed to avoid any negative interactions that can harm the patient (Meyer et al., 2022).

The care provider should also ask about the patient’s social history, including whether she lives alone or with family members, her participation in social activities, and the general support system for the patient. This information will be important in identifying individuals that can be instructed to provide care for the patient as she recovers since she is quite elderly. The social support can able be identify the bug that bites her, which can help decide the best drug options for the patient (Meyer et al., 2022)

What treatment would you prescribe?

The drugs to be prescribed for this patient include antibiotics and pain killers. Clarithromycin 500mg tablets would be the most appropriate prescription for this patient. She is allergic to penicillin, and therefore a macrolide would be an appropriate alternative. The full dosage is taken for seven days. Pain killers, including acetaminophen, would be appropriate to manage the pain she is experiencing (Dutta et al., 2021).

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