Week 3 SOAP Note LR - 2021

Week 3soap notesoapnursing 650nursingcaucasianfemaleI re injured my shoulder in November and it still isn’t healedInitials: L. Age: 56 Race: Caucasian Gender: Female Marital Status: In a monogamous relationship Source: Patient – appears to be a reliable source of information, alert and orients to person, place, time, and situation; ready recall and understanding of medical HXPatient reports injury occurred in November when she was on a ladder that started to tip; when her arms swung up to catch herself, she hit her R shoulder on scaffolding and felt a pop in her shoulder. Patient also reports that she had an injury to her R shoulder when she was 17 (separation) and it took 10 years to heal. L The patient reports the majority of her pain occurs in her R trapezius and deltoid. She says pain also radiates down her are to her R ring and pinky fingers. D She reports the pain is constant but increase and decrease in severity throughout the day based on her activity level. C At a base line she reports a dull pain 3/10 but reports certain movements can lead to a sharp pain 10/10. A The patient movements that include lifting or moving her arm when full extended aggravate her injury. Resting her arms to work (typing at a computer) on a surface that is too high aggravates her shoulder. The patient reports that she can sleep on her back comfortably but sleeping on either side also causes an increase in pain. T First thing in the morning the patient reports her pain is typically dull and her pain increases in severity throughout the day. R Immobilization provides the patient with the most relief. She has been doing exercises her chiropractor gave her and she thinks these are helping. In the evening her partner massages the should with a CBD rub and the patient says this helps her sleep. This injury has limited the patient in daily physical activity since November. She has adjusted her workstation and exercise practices to accommodate her injury. After days when she “over does it” she says she “can’t do anything” the next day. This is also affecting her relationship with her partner who feels the patient isn’t “helping out” enough .