Infected leg wound
Complete SOAP example
Example narrative
70-year-old woman from AL, ambulatory with walker, reports three days of increasing redness and pain around a chronic right-shin wound. Denies chest pain or dyspnea. History includes diabetes and peripheral vascular disease.
Primary survey intact. Patient found seated with leg elevated. Serial vitals obtained; temperature mildly elevated. Wound dimensions, surrounding erythema and drainage documented; distal CSM present. No crepitus or pain out of proportion.
Differential considerations: 1) cellulitis or wound infection, 2) deep-vein thrombosis, 3) deeper soft-tissue infection. Local infection features without current shock.
Wound protected using clean technique and limb positioned for comfort. Pain, redness boundary, perfusion and systemic findings reassessed. Transported; diabetes history, wound trend and findings transferred.