Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation and follow-up for cellulitis.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the onset, duration, and progression of cellulitis symptoms.
Explore for potential triggers, such as:
Skin injury (break in the skin)
Recent surgery or procedures
Insect bites
Chronic skin conditions (e.g., eczema, athlete’s foot)
Ask about associated symptoms like fever, chills, malaise (general feeling of unwellness).
Pain:
Characterize the pain associated with cellulitis (e.g., burning, throbbing) and its severity.
Functional Limitations:
Explore how cellulitis is impacting the patient’s daily activities.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate. Assess for fever or other signs of systemic infection.
Physical Exam:
Focus on the affected area and document:
Location, size, and erythema (redness) of the cellulitis
Induration (hardness) and swelling
Warmth to touch
Drainage (if present)
Tenderness to palpation
Briefly examine the lymph nodes in the drainage area for enlargement or tenderness.
Assess for any underlying skin conditions or signs of chronic lymphedema (if applicable).
Assessment (A):
Diagnosis:
Based on clinical presentation (characteristic skin findings), confirm the diagnosis of cellulitis.
Severity:
Briefly describe the severity of cellulitis based on the extent of involvement and systemic symptoms.
Site of Involvement:
Specify the location of the cellulitis (e.g., lower extremity, facial cellulitis).
Possible Causative Organism:
Consider potential causative organisms based on the location of cellulitis and other clinical features.
Note that definitive identification usually requires culture results.
Differential Diagnosis:
Briefly mention other conditions that might mimic cellulitis (e.g., erythema migrans (Lyme disease), allergic contact dermatitis, cellulitis vs. abscess).
Plan (P):
Antibiotics:
Initiate appropriate antibiotic therapy based on empiric coverage for likely skin flora and local resistance patterns.
Consider duration of treatment based on severity and response to therapy.
Wound Care:
Instruct on proper wound care, including:
Keeping the area clean and dry
Elevation of the affected extremity (if applicable)
Pain management with medications as needed
Consider referral to wound care specialist for complex wounds.
Re-evaluation:
Schedule a follow-up visit within 24-48 hours to assess response to treatment.
Additional Testing (if indicated):
In some cases, depending on severity or suspicion of atypical organisms, consider:
Blood cultures (if systemic symptoms are prominent)
Swab cultures of the affected area (yield is often low)
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., infectious disease)
Need for pain medication prescription
Patient education regarding adherence to antibiotics and wound care regimen
Importance of addressing underlying predisposing factors (e.g., lymphedema management, chronic skin conditions)
Discussion of potential complications of cellulitis (e.g., abscess formation, lymphangitis, sepsis)