Running head: MUSCULOSKELETAL SOAP NOTE 1
Musculoskeletal Soap Note
Patient Initials: Jackeline Washington
Age: 30
Gender: Female
Ethnicity: African
Chief Complaint (CC): Joints ache, hard to do her daily chores around the house.
History of Present Illness (HPI):
The patient is a 30-year-old female who complains of pain in the joints, mostly in her bilateral
fingers and wrists. She has experienced this for the past month but has progressively
deteriorated. She declares that she feels intense pain in the a.m. and often feels stiff, and it has
made her have a tough time doing her household chores. Besides, she indicates that the
stiffness/pain relieves as the day passes by. The patient asserts that her pain level is 9/10 in the
a.m. and lessens to a 3/10 in the afternoon. The patient is currently consuming OTC Tylenol and
OTC ibuprofen for the pain but asserts that it is not effective in alleviation most of the time. She
indicates that the morning pain feels like aching/stiff/throbbing lasting approximately three to
four hours. She adds that her hands feel and look swollen occasionally.
Current Medications:
Multi-Vitamin
OTC Tylenol 500mg
OTC ibuprofen 800mg
Victoza 1.8mg SC once daily
Metformin 500mg PO once daily
Allergies:
Seasonal allergies
Past Medical History (PMH):
1.) Diabetes type 2
Past Surgical History (PSH):
RT toenail extraction-Ingrown toenail
This study source was downloaded by 100000858936669 from CourseHero.com on 02-06-2023 11:10:40 GMT -06:00
https://www.coursehero.com/file/56420341/Musculoskeletal-soap-notedoc/
, Running head: MUSCULOSKELETAL SOAP NOTE 2
Mole Excision-Mid bac
Sexual/Reproductive History:
Menstruating
G0P0
Heterosexual
Social/Personal History:
She refutes smoking or second-hand smoke.
She does not take illicit drug use.
Drinks wine twice a month.
Immunization:
Flu Vaccine
Family History:
Mother 50 yrs. old- suffering from Chronic constipation and HLD
Father 60 yrs. old- suffering from GERD, TIA, and HLD
Lifestyle:
The patient is a personal injury attorney; she is married and has a daughter who is three years.
She stays with her husband and daughter in a low crime zone, and have functioning carbon
monoxide and smoke detectors in the house. The patient always uses her seatbelt while her
daughter uses a fitting car seat while driving.
ROS:
GENERAL: She denies chills, fever, and weight loss. The patient confesses to pain and
weakness in her hands in the a.m.
HEAD: She refutes dizziness, head injury, and headaches
HEENT:
Eyes: No yellow sclerae, double vision, blurred vision, and vision loss.
Ears: She repudiates pain in her ears, discharge, ringing, and ear infections.
Nose: The patient refutes sore throat, runny nose, congestion, sneezing, and bleeding.
NECK: The patient denies lumps and bumps in the neck region.
SKIN: She denies dryness, sores, discoloration, itching, and rash.
This study source was downloaded by 100000858936669 from CourseHero.com on 02-06-2023 11:10:40 GMT -06:00
https://www.coursehero.com/file/56420341/Musculoskeletal-soap-notedoc/
Musculoskeletal Soap Note
Patient Initials: Jackeline Washington
Age: 30
Gender: Female
Ethnicity: African
Chief Complaint (CC): Joints ache, hard to do her daily chores around the house.
History of Present Illness (HPI):
The patient is a 30-year-old female who complains of pain in the joints, mostly in her bilateral
fingers and wrists. She has experienced this for the past month but has progressively
deteriorated. She declares that she feels intense pain in the a.m. and often feels stiff, and it has
made her have a tough time doing her household chores. Besides, she indicates that the
stiffness/pain relieves as the day passes by. The patient asserts that her pain level is 9/10 in the
a.m. and lessens to a 3/10 in the afternoon. The patient is currently consuming OTC Tylenol and
OTC ibuprofen for the pain but asserts that it is not effective in alleviation most of the time. She
indicates that the morning pain feels like aching/stiff/throbbing lasting approximately three to
four hours. She adds that her hands feel and look swollen occasionally.
Current Medications:
Multi-Vitamin
OTC Tylenol 500mg
OTC ibuprofen 800mg
Victoza 1.8mg SC once daily
Metformin 500mg PO once daily
Allergies:
Seasonal allergies
Past Medical History (PMH):
1.) Diabetes type 2
Past Surgical History (PSH):
RT toenail extraction-Ingrown toenail
This study source was downloaded by 100000858936669 from CourseHero.com on 02-06-2023 11:10:40 GMT -06:00
https://www.coursehero.com/file/56420341/Musculoskeletal-soap-notedoc/
, Running head: MUSCULOSKELETAL SOAP NOTE 2
Mole Excision-Mid bac
Sexual/Reproductive History:
Menstruating
G0P0
Heterosexual
Social/Personal History:
She refutes smoking or second-hand smoke.
She does not take illicit drug use.
Drinks wine twice a month.
Immunization:
Flu Vaccine
Family History:
Mother 50 yrs. old- suffering from Chronic constipation and HLD
Father 60 yrs. old- suffering from GERD, TIA, and HLD
Lifestyle:
The patient is a personal injury attorney; she is married and has a daughter who is three years.
She stays with her husband and daughter in a low crime zone, and have functioning carbon
monoxide and smoke detectors in the house. The patient always uses her seatbelt while her
daughter uses a fitting car seat while driving.
ROS:
GENERAL: She denies chills, fever, and weight loss. The patient confesses to pain and
weakness in her hands in the a.m.
HEAD: She refutes dizziness, head injury, and headaches
HEENT:
Eyes: No yellow sclerae, double vision, blurred vision, and vision loss.
Ears: She repudiates pain in her ears, discharge, ringing, and ear infections.
Nose: The patient refutes sore throat, runny nose, congestion, sneezing, and bleeding.
NECK: The patient denies lumps and bumps in the neck region.
SKIN: She denies dryness, sores, discoloration, itching, and rash.
This study source was downloaded by 100000858936669 from CourseHero.com on 02-06-2023 11:10:40 GMT -06:00
https://www.coursehero.com/file/56420341/Musculoskeletal-soap-notedoc/
