SOAP NOTE Rheumatoid Arthritis (NURSINGMSN5500)

SOAP NOTE Rheumatoid Arthritis Name: C.M. Date: 04/08/2016 Time: 10:55 Pt. Encounter # Age: 52 Sex: Female SUBJECTIVE CC: “My hands are swollen and painful” HPI: This is a 51-year-old female who comes to the office with complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. Also, she report weight loss, anorexia, aching, and stiffness. Morning stiffness lasts for as long as 1 to 2 hours. Medications: 1. Diovan 80mg po daily 2. Singular 10mg po at bed time 3. Tylenol 500mg 1 tab po every 6 hours x pain 4. Albuterol 2 puff every 6 hours as needed PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: Hypertension, Asthma. Hospitalizations/Surgeries: Hysterectomy 5 years ago. Family History Mother diagnosed with: Asthma, Hypothyroidism, Rheumatoid Arthritis Father diagnosed with: HTN, Dementia Sister diagnosed with: HTN Social History Patient has a high school education. She works as a mail carrier for the post office for 15 years. She has been widowed for the last two years. Currently, she lives alone in a rented apartment. She has two living children, who all live close by and have families of their own. She reports her family is supportive and denies any needs at this time. She has adequate shelter and food. She denies any leisure activities. She refuses to practice exercises. She just goes to the local church on Sunday. She eats a diet low sodium. She denies substance use, ETOH, tobacco, marijuana or illicit drugs. ROS General Cardiovascular Weight loss and fatigue Denies chest pain, palpitations, PND, Decreased energy level orthopnea, edema Skin Respiratory Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen flat; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Deferred. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia: deferred Musculoskeletal: The wrists and small joints of the hands (metacarpophalangeal and proximal interphalangeal joints) are swelling, with deformity and limed range of motion. The skin over the affected joint look thin and shiny and have a ruddy color. Joint involvement is bilateral and symmetric. On palpation, the inflamed joint feels warm and tender and the synovial membrane feels thickened and boggy. Subcutaneous nodules over extensor surface of the elbow Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests 1. CBC: Normocytic, normochromic anemia is common in RA 2. Urinalysis 3. Serum creatinine and Hepatic panel: Evaluation of renal and hepatic functions is necessary because many antirheumatic agents have renal and hepatic toxicity and may be contraindicated if these organs are severely impaired 4. Acute-phase reactants are proteins that are synthesized rapidly by the liver in the presence of inflammation or tissue necrosis and include CRP, fibrinogen, complement proteins, and several other proteins. Measurement of serum