01_29_2024 SOAP note
docx
keyboard_arrow_up
School
University of Utah *
*We aren’t endorsed by this school
Course
MISC
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
4
Uploaded by CorporalGoat4107
Tutorials Spring 2024 SOAP Note (1/29/2024)
Gabriella Jones, PA-S
CA: Melanie
Access Medicine: Bone spurs in both hands and right foot
Patient:
D. Smith
Age:
53
Language:
English
Sex at birth:
Female
Source of hx:
Patient
Reliability:
Seems reliable CC:
Bone spurs on hands
Present illness:
DS presented to the clinic for concern of bone spurs on both hands. Pt said she started noticing hard bone spurs that have “appeared over time” on the Distal Interphalangeal joint
of the right hand fifth digit, and the left hand second digit distal interphalangeal joint. Nodules have mild tenderness to palpation but denies erythematous or swelling. Denies decrease range of motion. Denies any wrist pain. Patient said they do not interfere with her life. Pt came in for concern of either Rheumatoid Arthritis or Osteoarthritis. Denies morning stiffness, or any family history of Rheumatoid Arthritis. Denies the use of any medications for treatment of nodules. Denies decrease in activities of daily living. Denies any other joint swelling, stiffness, or erythema.
Past Medical History:
Childhood/Adult Illnesses:
Childhood illness:
Not addressed this visit.
Denies measles, mumps, rheumatic fever, CVD, murmur, HTN, hyperlipidemia, stroke, DVT, transfusions, cancer, TB, DM, STI, thyroid disease, asthma, arthritis, dementia, OSA, addictions,
epilepsy, depression, anxiety, history of any form of abuse, eating disorders. Hospitalizations/Injuries/Surgeries: - Denies any other hospitalizations, surgeries, or injuries
Drugs and environmental allergies:
- Allergy to Phenergan – reaction: muscle spasms - Denies any significant environmental allergies Current/Recent Medications:
Denies any current meds - med reconciliation on 1/25/2024
Denies supplements, OTC, or vitamins. Health Maintenance: Immunization status: Not addressed this visit.
Screening Tests: Not addressed this visit. Occupational & Environmental Exposures: Not addressed this visit.
Family History: Relative
Age/Gender
Status
Mother
(Age not given on chart)
Health history not given on chart
Father
(Age not given on chart)
Health history not given on chart
Child
(Age not given on chart)
History of seizures Denies family history of stroke, HTN, hyperlipidemia, cancer, tuberculosis, thyroid disease, arthritis, asthma, addictions, epilepsy, depression, anxiety, or other recurring diseases. Social History:
Alcohol/Tobacco/Drugs:
Denies the use of drugs or alcohol
Recreation/Exercise: Exercises for 30 mins, 3 times per week Educational history, occupational history, diet, caffeine intake, and living situation: did not address this visit.
ROS:
General:
Denies weight or appetite changes, fatigue, fever, chills, or night sweats.
Skin:
Denies pruritus, rash, skin changes.
HEENT:
Denies vision changes, corrective lenses, diplopia, or blurring. Denies hearing loss, tinnitus, and ear pain
. Denies nasal congestion and epistaxis. Denies for sore throat, hoarseness, dental problems, dentures, or neck swelling. Cardiopulm: Denies exercise intolerance change, wheezing, chest pain, palpitations, claudication, syncope, hemoptysis, dyspnea, orthopnea, PND, or edema.
MSK:
See HPI. Denies swelling, stiffness, back pain, or difficulty with ADLs.
Endo:
Denies temperature intolerance, weight change, menstrual changes, skin, hair, or voice change. Denies polydipsia and polyuria.
Objective: Vitals:
HR 91, O2 sat 99% on RA, BP 106/61 mmHg, Ht 160 cm, Wt 65.7 kg, BMI: 25.6, Temp and RR not given
General:
Alert female with no signs of distress. Appears comfortable.
Skin:
Patient denies pruritus, rash, or other changes MSK:
Positive for Heberden Nodules on the right hand fifth digit, and the left hand second digit distal interphalangeal joint. Full ROM of the thumb, fingers, and wrist. Median, ulnar, radial nerve sensation in tack. No cardinal signs of Kanavel No signs of deformities including negative for swan-neck or boutonniere bilaterally. Negative thumb CMC grind test bilaterally. Negative Gamekeepers thumb bilaterally. Negative Guyons tunnel compression test, and Tinels over Guyon’s tunnel bilaterally. Muscle mass symmetric bilaterally. Cardio:
Crisp S1 & S2. No audible murmurs in aortic, pulmonic, left sternal border, or apex positions. No visible heaves or palpable thrills. PMI palpable and is in midclavicular position. No JVD noted. JVP is 2cm above the sternal angle with bed elevated at 30 degrees. Dorsalis pedis and posterior tibial pulses strong bilaterally. Audible abdominal aorta, renal, iliac arteries. No trace of edema found
on lower extremities. Carotid, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses 2+. *Verbalized auscultating femoral arteries, palpating femoral pulses and inguinal node*
Pulm:
Lungs clear to auscultation. No visible heaves or palpable thrills. Thorax is symmetric with bilateral expansion. No retractions noted. No crackles, rhonchi, or
stridor heard bilaterally. No pain during rib spring or chest tenderness. Negative egophony, bronchophony, or whispered pectoriloquy. Equal and moderate vibrations present with tactile fremitus. Assessment/Medical Decision Making:
1.
Osteoarthritis (M19.90):
Symptoms present resemble Heberden’s node DIP joints on the right hand fifth digital as well as left hand second digit interphalangeal joint.
MDM:
Due to location of the nodules, no signs of Kanavel, her current health and
health history, antibiotic treatment is not indicated currently for flexor tendon sheath infection. Based on patients’ presentation, vitals, and physical exam I was able to rule out
osteoarthritis in the thumb, any UCL injury of the thumb, and any ulnar nerve entrapment. No family history of Rheumatoid arthritis, no morning stiffness, or any other joint pain on shoulders, wrists, knees, ankles, or feet I ruled out RA. Plan:
1.
Osteoarthritis (M19.90):
Patient educated on OTC Voltaren topical arthritis gel for relief, as well as oral NSAID treatment if needed. Informed to return to clinic if new symptoms appear or current symptoms get worse. Discussed ordering an X-ray if symptoms worsen or new joint paint occurs.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
Patient agreed to assessment and plan and was given the opportunity to ask any questions/provide any clarity. PICO Question:
In adults diagnosed with osteoarthritis, does the use of topical NSAIDs improve pain relief, compared to oral NSAID treatment?
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are commonly used to manage symptoms of osteoarthritis due to their anti-inflammatory and analgesic properties. This study focused on topical NSAIDs for chronic musculoskeletal pain in adults includes 39 studies involving 10,857 participants, with a focus on osteoarthritis. Topical diclofenac and topical ketoprofen were found to be significantly more effective than placebo for reducing pain in osteoarthritis. Furthermore, having multiple options for the treatment of joint pain is always good to study. Drug levels in the
blood with topical NSAIDs are much lower than with the same drug taken by mouth. This is a great alternative for patients with different health risks providers are trying to maneuver through and can allow evidence-based treatment to different individuals to minimizes the risk of harmful effects. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016 Apr 22;4(4):CD007400. doi: 10.1002/14651858.CD007400.pub3. PMID: 27103611; PMCID: PMC6494263.