SU_NSG6420_W10_A4_SANON_E (1)
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Florida Atlantic University *
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4826
Subject
Medicine
Date
Dec 6, 2023
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docx
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SOAP NOTE
1
SOAP NOTE Rheumatoid Arthritis
NSG6420
Elda Sanon
South University
Valessa Joseph
November 27, 2023
SOAP NOTE
2
Name:
S.T.
Pt. Encounter Number:
4
Date:
11/10/2023
Age:
68 years old
Sex:
Female
SUBJECTIVE
CC:
“I have pain and swelling in my joints.”
HPI:
S.T. is a 68 year old African American female whose chief complaint is pain and swelling
in her joints. She claims that the pain and swelling has gradually become worse over the
last few weeks. She claims the pain is mostly in her hands and legs and typically worse in
the morning. She also reports that she has experienced weight loss, aching, and stiffness
over the last few weeks. Her morning stillness can last for up to two hours. The pain is a
constant dull pain average about 5 out of 10, but sudden sharp pains range from about 8
to 10.
Patient is taking OTC pain medications. She is taking two Tylenol 500 mg tablets
every six hours for pain, but it only makes the pain bearable, but does not take it away.
Medications:
●
OTC pain medications Tylenol 500mg tablets - 2 tablets - Every 6 hours
PMH
Allergies:
No Known Allergy
Medication Intolerances:
None
Chronic Illnesses/Major traumas:
Hypertension
Hospitalizations/Surgeries:
Hysterectomy
Family History
Mother: 75 dead. Myocardial infarction. History of hypertension.
Father: 90 alive. History of hypertension and Type 2 diabetes.
Social History
Patient lives with her husband of 40+ years. She is fully retired and so is her husband.
She attends her doctors appointments on a regular basis and spends time with her
grandchildren on the weekend. She does not smoke or drink. She drinks about three cups
of hot tea per day. She does limited physical activity because of her pain.
ROS
General
Weight loss, fatigue, decreased energy
levels. Denies chills, or night sweats.
Cardiovascular
Denies chest pain and palpitations.
SOAP NOTE
3
Skin
Clean and dry.
Denies any bruising,
bleeding, or lesions.
Respiratory
Denies coughing, wheezing, shortness of
breath or any respiratory difficulties
Eyes
Patient wears reading glasses.
Gastrointestinal
Denies abdominal pain, constipation,
hepatitis, hemorrhoids, ulcers, black tarry
stools. Denies nausea or vomiting
Ears
Denies any hearing complications, ringing
in ears, hearing loss, or pain.
Genitourinary/Gynecological
No urgency. No burning. No change in
color of urine. No constipation.
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose
bleeds, hoarseness, or throat pain.
Musculoskeletal
Denies back pain, fracture history, or
osteoporosis. Patient does have swelling
and pain in her hands and knees.
Breast
Denies any chest changes.
Neurological
Denies syncope, seizures,
numbness, and
weakness.
Heme/Lymph/Endo
Denies heat or cold intolerance. Denies any
bruising
. Denies night sweats, increased
thirst, or change in appetite.
Psychiatric
Denies depression, anxiety, or difficulty
sleeping.
OBJECTIVE
Weight
185
BMI
29.9
Temp
98.6
BP
125/85
Height
5’6
Pulse
85
Resp
20
General Appearance
Patient is a 68 year old African American female. He is dressed appropriately and is well
groomed. Speaks clearly and answers questions appropriately.
He is under acute distress
due to pain and swelling.
Skin
Skin is brown, warm, and dry to the touch. Patient presents no rashes, lesions, or
bruising.
HEENT
Head: No head abnormalities or facial tenderness.
Eyes: Conjunctiva pink, corneas clear, no lid lag, PERRL, EOM intact.
Ears:
No ear complications.
Nose: Nasal mucosa pink. No septal deviation. No nasal drainage.
Neck: Full ROM. No occipital nodes. Oral mucosa is pink and moist. Tongue midline.
Teeth in good shape.
Cardiovascular
RRR, S1, S2 heard, no murmurs or other sounds.
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SOAP NOTE
4
Respiratory
Lungs clear bilaterally on auscultation.
Gastrointestinal
Bowel sounds active in all four quadrants. Abdomen soft, non-tender.
Breast
Free from masses or tenderness. No discoloration.
Genitourinary
Bladder is nondistended. Bladder is non-tender. No lymphadenopathy tenderness.
Musculoskeletal
Full ROM in all four extremities. Hands and knees are swollen, but no discoloration. She
has limited range of motion. Joint involvement is bilateral and symmetric. On palpation,
the swollen joint feels warm and tender to the touch.
Neurological
Speech clear. Posture erect. Balance stable. Gait steady.
Psychiatric
AAOx3. Appropriate mood and affect. Maintains eye contact. Answer questions
appropriately. Well groomed.
Lab Tests
CBC
Urinalysis
Serum Creatinine and Hepatic Panel
Anti-CCP antibodies
Special Tests
X-rays
MRI
Synovial fluid analysis
Diagnosis
Differential Diagnosis:
●
ICD-10-CM: M06.9 Rheumatoid Arthritis
○
Pain or aching in more than one joint
○
Stiffness in more than one joint
○
Tenderness and swelling in more than one joint
○
Same symptoms on both sides of the body
○
Weight loss
○
Fatigue
○
Weakness
●
ICD-10-CM: M19.90 Osteoarthritis
○
Pain of affected joints hurts more during or after movement
○
Stiffness - more apparent in the morning and after being inactive
○
Tenderness
○
Loss of flexibility
○
Bone spurs
SOAP NOTE
5
○
Swelling
●
ICD-10-CM: M32.9 Systemic lupus erythematosus
○
Pain and swelling of joints
○
Fever
○
Skin rash
○
Fatigue
Primary Diagnosis:
●
ICD-10-CM: M06.9 Rheumatoid Arthritis
○
Pain or aching in more than one joint
○
Stiffness in more than one joint
○
Tenderness and swelling in more than one joint
○
Same symptoms on both sides of the body
○
Weight loss
○
Fatigue
○
Weakness
PLAN
Further testing:
None
Medication:
●
NSAIDS
○
Diclofenae - 50 mg tablet orally three time a day
●
Glucocorticoids
○
Prednisone - 7.5 mg tablet orally once daily in the morning
Non-medication Treatments:
●
Exercise
●
Diet
●
Massage
●
Counseling
●
Stress Reduction
●
Physical Therapy
●
Surgery
Education:
Patient was educated on doing light exercise and starting physical therapy. Patient was
educated on the importance of taking her new medication regimen. Patient understands
that rheumatoid arthritis is a chronic condition, but with treatment the pain and swelling
will get better and more bearable. Patient was educated on lifestyle modifications such as
increased exercise and dietary modifications. Patient was educated on the benefits of a
warm shower in the morning to help with her stiffness.
Evaluation of Patient Encounter
Patient encounter went well. Patient was receptive to the physical exam. The patient
understood the treatment plan. Patient understands that she needs to exercise regularly
and attend physical therapy. Patient understands her medication regimen. Patient
SOAP NOTE
6
understands that the pain and swelling will likely not fully subside, but will get better and
more bearable with her treatment. She does have a follow-up appointment in 2 weeks.
References
ICD10Data.com (2023). 2024 ICD 10 CM diagnosis code M06.9: Rheumatoid arthritis.
Retrieved from https://www.icd10data.com/ICD10CM/Codes/M00-M99/M05-
M14/M06-/M06.9#:~:text=Rheumatoid%20arthritis%2C%20unspecified,-
2016%202017%202018&text=Billable%2FSpecific%20Code-,M06.,ICD
%2D10%2DCM%20M06.
ICD10Data.com (2023). 2024 ICD 10 CM diagnosis code M19.90: Unspecified
osteoarthritis site. Retrieved from https://www.icd10data.com/ICD10CM/Codes/M00-
M99/M15-M19/M19-/M19.90#:~:text=Unspecified%20osteoarthritis%2C
%20unspecified%20site,-2016%202017%202018&text=Billable%2FSpecific
%20Code-,M19.,effective%20on%20October%201%2C%2020
ICD10Data.com (2023). 2024 ICD 10 CM diagnosis code M32.9: Systemic lupus
erythematosus, unspecified. Retrieved from
https://www.icd10data.com/ICD10CM/Codes/M00-M99/M30-
M36/M32-/M32.9#:~:text=Systemic%20lupus%20erythematosus%2C%20unspecified,-
2016%202017%202018&text=Billable%2FSpecific%20Code-,M32.,ICD
%2D10%2DCM%20M32.
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