NURS 6512 Episodic/Focused SOAP Note Template
Patient Information:
F.P., age 46, Caucasian female
Subjective:
CC: Pain to both ankles, but more concerned about the right ankle
HPI: F.P. is a 46-year-old Caucasian female that presents with bilateral ankle pain. She is more concerned about the right ankle as she heard a “pop” while she was playing soccer over the weekend. She can uncomfortably bear weight to the right ankle. Patient describes the pain as achy and throbbing at times, over the lateral aspect of the right ankle. She currently rates the pain as a 4/10 at rest, and a 7/10 with ambulation. She did elevate and ice the right ankle after the injury. She has taken ibuprofen intermittently for pain relief with moderate results. The pain occasionally radiates approximately 4 inches up the lateral aspect of the right lower extremity. There was immediate swelling to the right ankle after the pop. Her left ankle bothers her at times, with an intermittent pain score of 3-4/10; however, there is no acute change to the left ankle at this time.
Current Medications:
1) Birth control pills
2) Effexor 37.5 mg p.o. daily for depression
3) OTC ibuprofen 600 mg p.o. Q6H prn, pain
Allergies: Denies allergies to drugs, food and latex. Denies environmental allergies.
PMHx: She receives a flu vaccine annually. She has been vaccinated for COVID-19. She received all childhood immunizations appropriately and was last vaccinated with a tetanus booster in 2017.
1) Depression, well-controlled on Effexor
2) C-section x 1
Soc Hx: Patient is married and has one child, age 13. She is a cashier at a local nursery. She was an athletic as a child. She does not smoke, drink, or use recreational drugs. She maintains her health playing soccer with friends and lifting weights 3 x a week. She drinks one cup of coffee daily. Her diet is plant-based. She has been a vegetarian for 10 years.
Fam Hx: Mother is 79, alive and well, with history of severe rheumatoid arthritis, depression, HTN. Father is 82, alive and well, with history of prostate cancer (in remission), mental health disorders (unspecified), HTN, HLD. She has one brother who is 53, alive and well, with “undiagnosed mental health disorders” but it otherwise healthy. Her son, age 13, is healthy. Health history of deceased grandparents include arthritis, colon cancer, prostate cancer, HTN, cirrhosis r/t alcoholism, HLD.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Denies headaches, changes to vision, hearing, taste, or smell.
SKIN: Denies rash or itching, easy bruising, or poor wound healing.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. Denies paroxysmal nocturnal dyspnea and orthopnea. Denies exercise intolerance.
PERIPHERAL VASCULATURE: Denies easy bruising, pain to calves, blood clots, or history of aneurysms.
MUSCULOSKELETAL: Endorses bilateral ankle pain, right greater than left, with swelling to right lateral ankle and difficulty bearing weight. She denies prior joint stiffness, bony deformities, decreased range of motion to bilateral ankles or any other joints.
NEUROLOGIC: Denies history of CVA or TIA, headaches, dizziness, concussion, seizures, weakness, vertigo, numbness and tremors.
MENTAL HEALTH: Reports history of depression which is well-controlled. She reports stable mood. Denies sleep disturbances, irritability, difficulty concentrating, and mood swings.
Objective:
Physical exam:
Vital signs: BP 128/64, HR 70, RR 17, temp 97.9˚F, pulse ox 99% on room air. Height: 5’5”, weight: 123. BMI: 20.5
General: well-developed, well-nourished 46-year-old Caucasian female in mild discomfort related to right ankle pain. She is pleasant and cooperative.
HEENT: Head is normocephalic and atraumatic. PERRLA, EOMI. Sclera anicteric.
Skin: Warm and dry. No noted rashes, wounds, lesions, or excess bruising. There is bruising to right lateral ankle.
Neck: Supple. Full range of motion.
Chest: lungs clear to auscultation. No cough or dyspnea. Heart regular, S1, S2 appreciated without murmurs, rubs, or gallops. No edema noted aside from right lateral ankle.
Peripheral vasculature: Bilateral dorsalis pedis pulses +2, Bilateral posterior tibial pulses +2, bilateral popliteal pulses +2, bilateral femoral pulses +2.
Musculoskeletal System: Right lateral ankle swollen, with decreased range of motion, weakness, and tenderness with palpation to lower aspect of fibula and surrounding ligaments (anterior and posterior tibiofibular ligaments, posterior and anterior talofibular ligaments, and calcaneofibular ligament) as well as lateral malleolus. There is generalized bruising to the lateral aspect of the right ankle. Medial aspect of right an