Internal Medicine SOAP Note Example: Cellulitis, Hospital Day 2
An inpatient progress note organized by problem: every active problem gets its own assessment and plan, with trends instead of just today's numbers.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Inpatient medicine progress notePatient: Fictional patient: 64-year-old man with type 2 diabetes, CKD stage 3a and hypertension
SSubjective
Reason for admission
Nonpurulent cellulitis of the left lower leg that progressed despite 3 days of outpatient cephalexin.
Interval history
"My leg feels less tight." Pain 3/10, down from 7/10 on admission. No fever or chills overnight. Eating normally. No new symptoms.
Medications (reconciled)
Home: metformin 1000 mg twice daily (held on admission), lisinopril 20 mg daily (held on admission for AKI), atorvastatin 40 mg nightly, insulin glargine 18 units nightly. Inpatient: cefazolin 2 g IV every 8 hours (day 2), insulin glargine 14 units nightly plus correction insulin, enoxaparin 40 mg subcutaneous daily.
Allergies
No known drug allergies.
ROS
Negative for fever, chest pain, shortness of breath, nausea, and diarrhea.
OObjective
Vital signs
T 37.1 °C (Tmax 37.6 °C; 38.6 °C on admission), HR 84 (102 on admission), BP 138/82, RR 16, SpO2 97% on room air.
Exam
General: comfortable, in no distress. Left lower leg: erythema, warmth and mild edema of the anterior shin; erythema has receded about 2 cm inside the border marked on admission. No fluctuance, crepitus, bullae or pain out of proportion. Maceration between the left 4th and 5th toes. Dorsalis pedis pulses 2+ bilaterally.
Labs (trend)
WBC 9.8 (15.2 on admission). Creatinine 1.3 (1.6 on admission; baseline 1.3). Fingerstick glucose 142-198 mg/dL. HbA1c 8.1%. Blood cultures from admission: no growth at 24 hours.
AAssessment
One-liner
64-year-old man with type 2 diabetes, CKD 3a and hypertension, hospital day 2 for left lower-leg cellulitis after failed outpatient therapy, improving.
Problem list
#1 Nonpurulent cellulitis, left lower leg — improving: erythema receding, afebrile more than 24 hours, WBC normalized. No signs of abscess or necrotizing infection. Likely portal of entry: interdigital tinea pedis. #2 Acute kidney injury on CKD 3a — resolved. Prerenal on admission; creatinine back to baseline after IV fluids. #3 Type 2 diabetes with hyperglycemia — not at goal (HbA1c 8.1%); inpatient glucose acceptable on basal plus correction insulin. #4 Hypertension — BP acceptable while lisinopril held.
PPlan
By problem
#1 Continue cefazolin 2 g IV every 8 hours. Change to oral cephalexin 500 mg every 6 hours once erythema keeps receding over the next 24 hours, for at least 5 days of total therapy, longer if not fully improved. Elevate the leg. Re-mark the border daily. Clotrimazole 1% cream between the left toes twice daily for 2-4 weeks. #2 Resume lisinopril 20 mg daily now that creatinine is at baseline. Repeat BMP in the morning. Avoid NSAIDs and other nephrotoxins. #3 Continue glargine 14 units nightly with correction insulin. Hold metformin while inpatient; resume at discharge (eGFR 58). #4 Lisinopril as in #2.
Prophylaxis
VTE: enoxaparin 40 mg subcutaneous daily.
Code status / goals of care
Full code, confirmed with the patient on admission.
Disposition / follow-up
Expected discharge tomorrow if afebrile and improving on oral antibiotics. Primary care follow-up within 1 week to recheck the leg and discuss diabetes control.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
Medications are reconciled: home versus inpatient, and why two home medications were held.
Each problem has a status (improving, resolved, not at goal) and its own numbered plan.
It shows trends (temperature, WBC, creatinine) rather than today's values alone.
It states what would change the plan: the conditions for switching to oral antibiotics and for discharge.
What students often miss
Reconciling home medications
Addressing chronic problems while treating the acute one
Stating what would change the plan
Internal Medicine SOAP note template
Complex adults with several problems at once. The note is organized around a problem list.
SSubjective
Chief complaint / reason for visit
HPI
For each active problem: course since last visit, new symptoms, pertinent negatives.
Medications
Reconciled: what they actually take, dose, route, frequency, adherence.
Allergies
Drug and reaction.
PMH / PSH / FH / SH
Updated.
ROS
Pertinent positives and negatives.
OObjective
Vital signs
With trends.
Exam
Focused by system, problem-relevant.
Labs / imaging
Today's results with prior values for comparison.
AAssessment
One-liner
Problem list
#1 most acute → chronic. For each: status (new, improving, worsening, stable) and reasoning.
PPlan
By problem
Diagnostics, therapeutics, monitoring for each numbered problem.
Prophylaxis
e.g. DVT prophylaxis for inpatients, when relevant.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.