Daniel DeMarco SOAP Note #4 Pediatrics

 

S

 

SL is an 18yo male with h/o MRSA cellulitis admitted with Right 4th toe cellulitis and abscess. He is s/p I&D 6/14 and repeat I&D 6/17 with Podiatry. Patient had no overnight events. Endorses non-radiating pain at Right 4th toe. Denies pain elsewhere, fever, chills, nausea, vomiting, diarrhea.

 

O

 

V/S

T 36.5C (36.4-36.8)

HR 64bpm (60-69)

RR 16bpm (15-19)

SpO2 97%RA (96-98)

BP 113/70 (105/63-129/71)

Wt: 94.5kg

 

I/Os

Ins: 0.78x MIVF

Outs: 0.90 cc/kg/hr

 

Labs

Wound Culture: S. aureus; Sensitivity Pending

 

Diagnostic Imaging

6/17

XR – No radiographic evidence of osteomyelitis.

 

PE

General: AOx3. NAD.

Skin: Warm, moist. No jaundice, cyanosis, mottling.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

Extremities: R foot secured in dressing by Podiatry. No proximal streaking. Capillary refill <2s throughout. + Sensation in R Leg and R Foot.

 

A

 

SL is an 18yo male with h/o MRSA admitted for IV antibiotics in the setting of worsening Right 4th toe cellulitis and abscess. Now improving and well-appearing, hemodynamically, and clinically stable.

 

P

 

#R 4th Toe Cellulitis and Abscess

– Cont. Levofloxacin 750mg IV q24h (6/17 – x 14d)

– Cont. Sulfamethoxazole/Trimethoprim DS Tab PO qd (6/19 – x 14d)

– Requested sensitivity from initial wound cx performed by outpatient Podiatry

– F/u sensitivity from wound cx

 

#Pain 2/2 inflammation

– Cont. APAP 600mg PO q6h PRN for pain

 

#FEN/GI

– Regular Diet

– I/Os

 

Disposition: Plan for discharge today after receiving sensitivity results and appropriate abx selection and duration (coverage of Proteus and S aureus. Speak with ID for duration of treatment). Patient scheduled to f/u with Podiatrist on Friday. PT for Uniboot. Low threshold to return if systemic signs of infection, worsening R toe pain, purulent drainage, etc.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student