Select a patient who you examined during the last 4 weeks. With this patient in mind, address the following in a SOAP Note:

• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

I NEED A POSITIVE COMMENT BASED IN THIS POST  ..BETWEEN 100 TO 120 WORDS.

In regards to Ms. G, I would first want a full set of vital signs – her temp is 102 and higher I would want to assess her blood pressure and pulse, in our local hospital we have sepsis protocol and dependent on the other vital signs there may be a plan of care in place. Blood cultures may need to be ordered along with IV fluids and IV antibiotics. In addition, with her being in bed for the last three days and immobile I would want a Doppler study to assess the leg that we know measures larger and is painful with weight bearing, we know there is infection but we also need to assess circulation.

For a plan of care I would assess measurement every shift, elevate the foot and continually reassess vital signs. In regards to her BMI, she is above normal range and for long term care plan I would have dietary consult and have a full assessment in regards to her diet control and long term plan.

The muscle group likely to be affected would be the flexor halluces, flexor digitorum.  

The significance of her lab values would be the WBC count being elevated, along with reassessing the wbc and the culture of the open wound I would continue to evaluate the vital signs and obtain cultures when needed. In addition, as we know blood sugar control is essential in wound healing so we would have to have patient on blood sugar checks and most likely a sliding scale for blood sugar management.

The main factors in wound healing are the known staph infection, the known fact of diabetes, and the unknown factors of how educated or how well she manages her diabetes. I would request a wound care consult and most likely put her in a private room with wound care precautions being mindful not to introduce any other issues to the situation. For discharge planning I would ask for case management consult to identify patient needs, education, financial and follow up on wound care possible wound care by home health since she lives at home. It is noted that patient with diabetes are at a higher risk for infections, what may be commonly on the skin when dealing with a diabetic patient it increases the risk of infection setting in, “each year with diabetes increases the risk factor for more infections”. (Preidt, R, 2016).

                                                                  Reference

Preidt, R (2016). Diabetes May Raise Dangerous Staph Infection Risk. Retrieved from http://www.webmd.com/diabetes/news/20160311/diabetes-may-raise-risk-for-dangerous-staph-infection