What is the appropriate SOAP note for a 66-year-old female with a past medical history of non-insulin-dependent (Type 2) diabetes mellitus, peripheral neuropathy, and status post Below-Knee Amputation (BKA) presenting with a right foot ulcer?

From the Guidelines

The appropriate SOAP note for a 66-year-old female with a past medical history of non-insulin-dependent (Type 2) diabetes mellitus, peripheral neuropathy, and status post Below-Knee Amputation (BKA) presenting with a right foot ulcer is:

S - Subjective

• Chief Complaint: Patient presents with a right foot ulcer
• History of Present Illness: The patient has a history of Type 2 diabetes mellitus, peripheral neuropathy, and a previous BKA, which increases her risk for foot complications, including ulcers and infections 1
• Symptoms: The patient may report pain, swelling, redness, or warmth around the ulcer, although these symptoms may be masked by peripheral neuropathy 1

O - Objective

• Physical Examination: Examination of the right foot reveals an ulcer, with possible signs of infection such as redness, warmth, swelling, or purulent discharge 1
• Vital Signs: The patient's vital signs should be monitored, including temperature, blood pressure, and heart rate, to assess for signs of systemic infection

A - Assessment

• Diagnosis: Diabetes-related foot ulcer, possibly infected, given the patient's history and presentation 1
• Severity: The severity of the ulcer and any infection should be assessed, using classification systems such as those described in the IWGDF guidelines 1

P - Plan

• Offloading: The patient should be advised on offloading strategies to reduce pressure on the ulcer, such as using a non-removable knee-high offloading device for mild infection or ischaemia, or a removable offloading device for more severe cases 1
• Wound Care: The patient should receive guidance on wound care, including debridement, dressing, and monitoring for signs of infection 1
• Infection Management: If the ulcer is infected, the patient should receive appropriate antimicrobial therapy, as guided by culture results and clinical judgment 1
• Follow-up: Regular follow-up appointments should be scheduled to monitor the ulcer's healing progress and adjust the treatment plan as necessary 1

From the Research

Patient Presentation

The patient is a 66-year-old female with a past medical history of non-insulin-dependent (Type 2) diabetes mellitus, peripheral neuropathy, and status post Below-Knee Amputation (BKA) presenting with a right foot ulcer.

Relevant Medical History

• Non-insulin-dependent (Type 2) diabetes mellitus: increases the risk of foot ulcers and peripheral neuropathy 2, 3
• Peripheral neuropathy: loss of sensation in the feet, making it difficult to detect foot ulcers 4, 2, 3
• Status post Below-Knee Amputation (BKA): increases the risk of foot ulcers and complications in the remaining foot 4, 3

SOAP Note

Subjective

• Patient reports a right foot ulcer
• Patient has a history of peripheral neuropathy and may not feel pain or discomfort in the affected foot 4, 5

Objective

• Physical examination of the right foot reveals an ulcer
• Assessment of the circulation and sensation in the foot is necessary to determine the extent of the neuropathy and peripheral vascular disease 2, 3

Assessment

• Diabetic foot ulcer with possible peripheral neuropathy and peripheral vascular disease 4, 2, 3
• Risk factors for ulceration and amputation include male gender, presence of neuropathy, and peripheral vascular disease 3

Plan

• Offloading of the affected foot to prevent further trauma and promote healing 4
• Aggressive treatment of any infection present 4
• Arteriography and surgical management if peripheral vascular disease is suspected 4
• Patient education on foot care and regular follow-up appointments to prevent future ulcers and complications 2, 3