Past medical history of an old man SOAP note Assignment

M.L. is a 40 year old male with a past medical history of type 2 diabetes mellitus with significant neuropathy, hypertension and a past surgical history of right metatarsal osteomyelitis. He presents to hospital with fever, right ear pain, headache, two episodes of diarrhea and redness and blistering to the right 3rd metatarsal. Upon examination he was noted to have a 1 cm ulceration on the right 3rd toe on the dorsal aspect associated with redness and edema. Temp; 38.0 C. Bl pr; 122/76, RR 20, P; 87.

Meds(S)

• Novolin 70/30 60 units Q AM and Q PM
• Metformin 1,000 mg po twice daily
• Aspirin 81 mg po once daily
• Lisinopril 20 mg po once daily

All (S)

• Sulfa-severe rash

Blood cultures were performed and Gram stains performed on the positive blood culture broth showed gram negative rods (Salmonella species Group B).

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