lOMoAR cPSD|
MUSCULOSKELET
AL FOCUSED SOAP
NOTE
SUBJECTIVE
Patient information:
Name: Shoshanna Tillman
Gender: Female
Ethnicity: white American
Age: 39 y/o Weight: 54kg Height: 160cm
CC: “I’m here to follow up on my last visit about my joint pain and how tired I am.”
, lOMoARcPSD|14985576
2
HPI (History of Present Illness): Shoshanna Tillman is a 39-year-old white American female who
presents to the clinic complaining of joint pain and fatigue. The joint pain is constant and started
three months ago. The pain is mainly located in her hands and wrists. The pain is worse in the
morning. The patient complains of dull, throbbing, and stiff pain in the wrists and hands. The
patient also complains of body aches. The full-body pain is described as stiff and achy. The
patient states her current pain is 2 out of 10. Mrs. Tillman says that hot showers and Diclofenac
help decrease joint pain. However, she states that when she uses her hands for a long time, the
joint pain worsens. The patient comments that sitting too long also irritates her joint pain. Before
Diclofenac, the pain is rated as a 3 or 4 out of 10. The fatigue is constant and started three
months ago. There are no aggravating or relieving factors for the fatigue, which worsens as the
day progresses. The patient also complains of intermittently feverish, decreased appetite, and
weight loss for the past month. The patient can perform her activities of daily living without pain
but states that she feels drained after, and it takes longer than usual.
Onset: The joint pain started three months ago.
Location: Hands and wrists and total body pain
Duration: Pain is worse in the morning; when she wakes up, the pain is constant
Characteristics: The pain is dull, throbbing, and stiff, and full-body pain stiff and achy
Aggravating Factor: The joint pain worsens when she uses her hands for a long time or if she
sits for too long.
Relieving Factors: Long, hot showers and Diclofenac.
Treatments: diclofenac sodium in lowering the pain level
PMH (Pertinent past medical history): Denies medical history. Denies mental health conditions.
Denies environmental hazards. Denies recent travel.
MUSCULOSKELET
AL FOCUSED SOAP
NOTE
SUBJECTIVE
Patient information:
Name: Shoshanna Tillman
Gender: Female
Ethnicity: white American
Age: 39 y/o Weight: 54kg Height: 160cm
CC: “I’m here to follow up on my last visit about my joint pain and how tired I am.”
, lOMoARcPSD|14985576
2
HPI (History of Present Illness): Shoshanna Tillman is a 39-year-old white American female who
presents to the clinic complaining of joint pain and fatigue. The joint pain is constant and started
three months ago. The pain is mainly located in her hands and wrists. The pain is worse in the
morning. The patient complains of dull, throbbing, and stiff pain in the wrists and hands. The
patient also complains of body aches. The full-body pain is described as stiff and achy. The
patient states her current pain is 2 out of 10. Mrs. Tillman says that hot showers and Diclofenac
help decrease joint pain. However, she states that when she uses her hands for a long time, the
joint pain worsens. The patient comments that sitting too long also irritates her joint pain. Before
Diclofenac, the pain is rated as a 3 or 4 out of 10. The fatigue is constant and started three
months ago. There are no aggravating or relieving factors for the fatigue, which worsens as the
day progresses. The patient also complains of intermittently feverish, decreased appetite, and
weight loss for the past month. The patient can perform her activities of daily living without pain
but states that she feels drained after, and it takes longer than usual.
Onset: The joint pain started three months ago.
Location: Hands and wrists and total body pain
Duration: Pain is worse in the morning; when she wakes up, the pain is constant
Characteristics: The pain is dull, throbbing, and stiff, and full-body pain stiff and achy
Aggravating Factor: The joint pain worsens when she uses her hands for a long time or if she
sits for too long.
Relieving Factors: Long, hot showers and Diclofenac.
Treatments: diclofenac sodium in lowering the pain level
PMH (Pertinent past medical history): Denies medical history. Denies mental health conditions.
Denies environmental hazards. Denies recent travel.
