Please write this Soap Note on the Topic 41 year old male with Bilateral Leg Pain when he stands for a long time but is releived when he rest.

Sample Answer

Age 41 years Sex Male

Subjective

CC ‘I experience pain in both my legs when I stand for a long period. Resting relieves it.’
HPI ZE is a 41-year-old male who came to the clinic with complaints of pain in both legs when he stands for a long time. The patient reports that resting relieves the pain.

He notes that the problem started six months ago and has been worsening over time. He reports that the bilateral leg pain worsens when he engages in strenuous activities such as walking for long distances. The accompanying symptoms of his problem include cool extremities and pain being referred in some instances to the buttocks.
Medications ZE reports that he has been taking Tylenol 1 mg as needed for occasional headaches. He denies any other current use of medications.

PMH

Allergies The patient reports that he is allergic to pollen and dust. He does not have any food or drug allergies.
Medication Intolerances The patient denied any history of drug allergies.
Chronic Illnesses/Major traumas The patient reports that he has been diabetic for the last three years. He controls it with oral hypoglycemic medications, exercise, and dietary modification.

Hospitalizations/Surgeries The patient was admitted in 2021 due to bacterial pneumonia. He has no history of surgeries.

Family History The patient reports that his father is diabetic while his mother has hypertension. His grandfather died of coronary artery disease. His deceased grandmother had major depression. His first-born son is an alcoholic.

Social history ZE’s highest level of education is university. He currently works as an engineer. He is married with three sons. He lives with his family in a rented apartment. He has been smoking at least a pack of cigarettes for the past year. He does not smoke. He wears a helmet while riding a bicycle.

ROS

General The patient denies fatigue, fever, chills, night sweats, and recent weight gains, or losses of significance.
HEENT The patient denies changes in vision or hearing. He does not wear corrective lenses. He denies a history of glaucoma, diplopia, floaters, excessive tearing, or photophobia.

He denies recent ear infections, tinnitus, or discharge from the ears. He denies changes in the sense of smell. He denies epistaxis, sinus congestion, or nasal polyps. He denies ulceration, lesions, gingivitis, and gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.

Neck The patient denies neck pain, injury, or jugular venous distention.
Breasts The patient denies a history of lesions, masses, or rashes. Respiratory The patient denies cough, hemoptysis, difficulty breathing, or chest pain.

CV The patient denies chest discomfort, palpitations, and a history of murmur, arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, and edema. GI The patient denies nausea or vomiting, reflux, abdominal pain, and changes in bowel pattern.

GU The patient denies change in urinary pattern, dysuria, or incontinence. He is heterosexual. He also denies a history of sexually transmitted infections.

MS The patient reports bilateral leg pain with standing, which resting relieves. He denies arthralgia/myalgia, arthritis, and limited range of motion.

Psych The patient denies a history of anxiety or depression. He also denies sleep disturbance, delusions, or mental health history.

Neuro The patient denies syncope episodes, paresthesia, headaches, and changes in memory or thinking patterns, twitches, or abnormal movements.

Integument/Heme/Lymph The patient denies rashes, itching, or bruising. He reports occasional cold extremities. He denies any bleeding disorders.

Endocrine He denies polyuria, polyphagia, polydipsia, fatigue, heat or cold intolerance, and unintentional weight gain or weight loss.

OBJECTIVE DATA

Physical Exam

Vital signs B/P 126/78, left arm, sitting, regular cuff; P 80 and regular; T 99.9 Orally; RR 18; non-labored; Wt 180 lbs; Ht 5’8; BMI 30.0
General A&O x3, NAD, comfortable

HEENT PERRLA, EOMI, oronasopharynx is clear
Neck Carotids no bruit, jugular venous distention, or thyromegaly
Chest/Lungs Lungs negative of wheezing, rhonchi or labored breathing
Heart/Peripheral Vascular Absence of adventitious heart sounds with pulses+1 bilateral pedal and +2 radial

ABD normal bowel sounds, absence of abdominal mass or surgical scars
Genital/Rectal Noncontributory

Musculoskeletal There is symmetric muscle development with 5/5 muscle strengths in all groups. Bilateral pedal pulses reduced. Lower extremities are cold to the touch.
Neuro Absence of ataxia, tremors, and problems in coordination
Skin/Lymph Nodes There is bilateral lower limb cold skin with no hair loss. There is no edema, clubbing, cyanosis, or palpable nodes

Psychiatric He is dressed appropriately for the occasion. He is alert and oriented to self, others, time, and events. He maintains normal eye contact with normal speech tone and rate.

Lab tests
Lipid profile pending
Hba1c 8.5
Doppler ultrasound ABI 0.5
Diagnosis

Differential diagnoses
1. Venous insufficiency
2. Vasculitis
3. Sciatica

Primary diagnosis

 Intermitted claudication Intermitted claudication is ZE’s primary diagnosis. Intermitted claudication is a condition that develops from insufficient delivery of oxygen to meet the demands of the muscles. It is an indicator of peripheral artery disease.

Patients experience symptoms such as muscle pain during exercise or prolonged standing. Resting relieves the pain. The pain may be localized to the lower leg or buttocks depending on the region of blood occlusion.

Smoking is the leading risk factor for intermitted claudication (Waddell et al., 2022). ZE has these symptoms and risk factors; hence, intermittent claudication is the primary diagnosis.

Plan/Therapeutics

No further testing was ordered for the patient. Medical management for intermitted claudication was adopted. It included educating the patient about smoking cessation, prescribing statin therapy, antiplatelet medications, and cilostazol, and developing a structured walking program.

The patient was educated about the risks of intermitted claudication, the importance of smoking cessation, treatment adherence, and engaging regularly in a structured walking program.

The combination of pharmacological interventions and non-pharmacological therapies improves outcomes and prolongs risks such as limb amputation (Harwood et al., 2020; Woo et al., 2022). The patient was scheduled for a follow-up visit after one month to assess his response to treatment.

References

• Harwood, A. E., Pymer, S., Ingle, L., Doherty, P., Chetter, I. C., Parmenter, B., Askew, C. D., & Tew, G. A. (2020). Exercise training for intermittent claudication A narrative review and summary of guidelines for practitioners. BMJ Open Sport &
• Exercise Medicine, 6(1), e000897. https //doi.org/10.1136/bmjsem-2020-000897
  Waddell, A., Seed, S., Broom, D. R., McGregor, G., Birkett, S. T., & Harwood, A. E. (2022). Safety of home-based exercise for people with intermittent claudication A systematic review. Vascular Medicine, 27(2), 186–192. https //doi.org/10.1177/1358863X211060388
  
• Woo, K., Siracuse, J. J., Klingbeil, K., Kraiss, L. W., Osborne, N. H., Singh, N., Tan, T.-W., Arya, S., Banerjee, S., Bonaca, M. P., Brothers, T., Conte, M. S., Dawson, D. L., Erben, Y., Lerner, B. M., Lin, J. C., Mills, J. L., Mittleider, D., Nair, D. G., … Simons, J. P. (2022). Society for Vascular Surgery appropriate use criteria for management of intermittent claudication. Journal of Vascular Surgery, 76(1), 3-22.e1. https //doi.org/10.1016/j.jvs.2022.04.012