Left Calf Severe Pain SOAP Note Worksheet

• Based on this patient case, and using the focused SOAP note as a reference, develop a case study presentation that includes the history of present illness (HPI), appropriate positive and negative physical exam findings, past medical and surgical history, diagnostic results, diagnosis including differentials that were ruled out, and treatment plan.
• Your presentation should also include objectives for your audience (see the resource on Bloom’s Taxonomy), at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.

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Case study

A 65-year-old man was sent to the clinic for worsening of left calf severe pain and decrease in exercise tolerance due to left calf pain. The patient had a 3-month history of intermittent left calf pain and denied trauma, back pain, fever, and leg weakness. Otherwise, the medical history was significant for hyperlipidemia. He was a former smoker and stopped smoking 6 months ago; however, he smoked 1 pack of cigarettes per day for the past 40 years before quitting. The patient denied use of alcohol or recreational drugs. His medications were low-dose aspirin and high-intensity atorvastatin. On physical examination, vital signs were normal. Body mass index was 28 kg/m2. Femoral pulses were diminished bilaterally. Popliteal, right dorsalis pedis, and right posterior tibialis pulses were faint. The left dorsalis pedis and posterior tibialis pulses were not palpable. Cardiac examination was normal. Otherwise, the physical examination was unremarkable. The ankle-brachial index was 0.67 on the left and 0.91 on the right. He was enrolled in a supervised exercise program 3 months ago, but the patient reported no improvement despite adherence to the exercise program, and his symptoms progressed

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