NURS 6531 Week 8 assignment:
Comprehensive SOAP Note : Musculoskeletal
Patient Initials: SS Age: 35 Gender: Female
S:
Chief Complaint (CC): Joints hurt, difficult to do normal daily things around the
house.
History of Present Illness (HPI): Patient SS is a 35-year-old female that presents
to her primary care physician with complaints of joint pain mainly in her bilateral
wrists and fingers, this has been going on for about 1 month but has gradually gotten
worse. Patient states she has more pain in the morning and feels stiff, which has
caused her difficulty in preforming daily chores/routine activities. She states the pain/
stiffness gets better as the day goes on. She states her pain is a 9/10 in the morning
and subsides to a 3/10 in the midmorning/afternoon. She is taking OTC ibuprofen
and OTC Tylenol for the pain but states that it is not providing enough relief at her
most painful times. Patient SS states that her pain in the morning feels like it is
throbbing/stiff/aching lasting about 3-4 hours. Patient SS states that she also has
noticed that her hands look and feel swollen sometimes.
Medications:
1.) Metformin 500mg PO once daily
2.) Victoza 1.8mg SC once daily
3.) OTC ibuprofen 800mg BID PRN for pain
4.) OTC Tylenol 500mg Q4hrs PRN for pain
5.) Multi Vitamin
Allergies:
NKDA/No food allergies/Positive for Seasonal allergies
Past Medical History (PMH):
1.) Diabetes type 2- December 15,2018-Metformin and Victoza
Past Surgical History (PSH):
1.) Mole Excision-Mid bac-October,2018-Benign
2.) RT toe nail removal-Ingrown toe nail-2004
Sexual/Reproductive History:
Heterosexual
G0P0
Menstruating, first day of last cycle 12/15/18
Page 1 of 7
, Personal/Social History:
Patient SS denies smoking, denies exposure to second hand smoke, denies illicit
drug use, drinks wine 1-2 times a month.
Immunization History:
Flu Vaccine-10/10/18
Significant Family History:
Mother 56 yrs. old- HLD, Chronic constipation,
Father 59 yrs. old-HLD, TIA, GERD,
Paternal Grandfather 76 yrs. old-CABG, DM2, HTN, HLD
Paternal Grandmother 74 yrs. old-RA, Hypotension, GERD,
Maternal Grandfather 77 yrs. old-DM2, A fib, HTN, HLD, BPH
Maternal Grandmother 75 yrs. old-RA, OA, Lupus, HLD, Diverticulitis
Lifestyle:
Patient SS is married, with one 2-year-old little girl and 3 dogs. She is a personal
injury attorney. She lives with her husband and child on the outskirts of the city in a
low crime area, and have working smoke detectors and carbon monoxide detectors
in the house. She always wears her seatbelt and the child always rides in the
appropriate care seat, no texting or cell phone use is done while driving. Family is
very involved in church events and both sets of grandparents are secondary
caregivers for the child during the parent’s working hours. The patient and her
husband are both college graduates and financially stable. She has a good support
system of family and friends.
ROS:
GENERAL: Patient denies weight loss, fever, chills, patient report weakness and pain in
her hands in the morning that last a couple hours.
HEAD: Patient denies head ache, head injury, dizziness
EENT: Eyes: Patient has no visual loss, blurred vision, double vision or yellow sclerae.
Ears: Patient denies ear infections, ringing, discharge and or pain in her ears. Nose:
Patient denies bleeding, sneezing, congestion, runny nose or sore throat.
NECK: Patient denies bumps, lumps in neck area.
SKIN: Patient denies rash, itching, discoloration, sores, dryness or problem areas.
Patient states she had a mole excised from her midback in October 2018 with pathology
coming back benign.
BREASTS: Patient denies breast changes, no lumps, bumps, nipple discharge, nipple
color changes, breast color changes, dimpling or pain.
Page 2 of 7
Comprehensive SOAP Note : Musculoskeletal
Patient Initials: SS Age: 35 Gender: Female
S:
Chief Complaint (CC): Joints hurt, difficult to do normal daily things around the
house.
History of Present Illness (HPI): Patient SS is a 35-year-old female that presents
to her primary care physician with complaints of joint pain mainly in her bilateral
wrists and fingers, this has been going on for about 1 month but has gradually gotten
worse. Patient states she has more pain in the morning and feels stiff, which has
caused her difficulty in preforming daily chores/routine activities. She states the pain/
stiffness gets better as the day goes on. She states her pain is a 9/10 in the morning
and subsides to a 3/10 in the midmorning/afternoon. She is taking OTC ibuprofen
and OTC Tylenol for the pain but states that it is not providing enough relief at her
most painful times. Patient SS states that her pain in the morning feels like it is
throbbing/stiff/aching lasting about 3-4 hours. Patient SS states that she also has
noticed that her hands look and feel swollen sometimes.
Medications:
1.) Metformin 500mg PO once daily
2.) Victoza 1.8mg SC once daily
3.) OTC ibuprofen 800mg BID PRN for pain
4.) OTC Tylenol 500mg Q4hrs PRN for pain
5.) Multi Vitamin
Allergies:
NKDA/No food allergies/Positive for Seasonal allergies
Past Medical History (PMH):
1.) Diabetes type 2- December 15,2018-Metformin and Victoza
Past Surgical History (PSH):
1.) Mole Excision-Mid bac-October,2018-Benign
2.) RT toe nail removal-Ingrown toe nail-2004
Sexual/Reproductive History:
Heterosexual
G0P0
Menstruating, first day of last cycle 12/15/18
Page 1 of 7
, Personal/Social History:
Patient SS denies smoking, denies exposure to second hand smoke, denies illicit
drug use, drinks wine 1-2 times a month.
Immunization History:
Flu Vaccine-10/10/18
Significant Family History:
Mother 56 yrs. old- HLD, Chronic constipation,
Father 59 yrs. old-HLD, TIA, GERD,
Paternal Grandfather 76 yrs. old-CABG, DM2, HTN, HLD
Paternal Grandmother 74 yrs. old-RA, Hypotension, GERD,
Maternal Grandfather 77 yrs. old-DM2, A fib, HTN, HLD, BPH
Maternal Grandmother 75 yrs. old-RA, OA, Lupus, HLD, Diverticulitis
Lifestyle:
Patient SS is married, with one 2-year-old little girl and 3 dogs. She is a personal
injury attorney. She lives with her husband and child on the outskirts of the city in a
low crime area, and have working smoke detectors and carbon monoxide detectors
in the house. She always wears her seatbelt and the child always rides in the
appropriate care seat, no texting or cell phone use is done while driving. Family is
very involved in church events and both sets of grandparents are secondary
caregivers for the child during the parent’s working hours. The patient and her
husband are both college graduates and financially stable. She has a good support
system of family and friends.
ROS:
GENERAL: Patient denies weight loss, fever, chills, patient report weakness and pain in
her hands in the morning that last a couple hours.
HEAD: Patient denies head ache, head injury, dizziness
EENT: Eyes: Patient has no visual loss, blurred vision, double vision or yellow sclerae.
Ears: Patient denies ear infections, ringing, discharge and or pain in her ears. Nose:
Patient denies bleeding, sneezing, congestion, runny nose or sore throat.
NECK: Patient denies bumps, lumps in neck area.
SKIN: Patient denies rash, itching, discoloration, sores, dryness or problem areas.
Patient states she had a mole excised from her midback in October 2018 with pathology
coming back benign.
BREASTS: Patient denies breast changes, no lumps, bumps, nipple discharge, nipple
color changes, breast color changes, dimpling or pain.
Page 2 of 7
