I human case study# week 3 reason for
encounter ARM WEAKNESS with a full SOAP
NOTE REAL!!! 2025 NEW!!!
Week 3 I-Human Case | Reason for Encounter: Arm Weakness – History
Chief Complaint (CC)
“My arm feels weak.”
Patient presents with new-onset weakness of the ____ arm (left/right—fill in based on your case).
History of Present Illness (HPI)
• Onset: When did the arm weakness begin? Sudden or gradual?
• Location: Entire arm vs. specific area (shoulder, forearm, hand).
, • Duration: Continuous or intermittent?
• Characteristics:
o Difficulty lifting objects?
o Trouble with grip strength?
o Any numbness, tingling, or pain?
o Any dropping of objects?
• Associated Symptoms:
o Headache
o Facial droop
o Speech difficulty
o Vision changes
o Neck pain
o Recent viral illness
• Aggravating/Relieving Factors:
o Movement, rest, neck movement, overhead activities, repetitive use.
• Severity: Impact on ADLs (buttoning shirt, writing, carrying items).
• Context:
o Any trauma, fall, sports injury, or heavy lifting?
o Recent vaccination or injection?
o Recent illness, fever, or tick exposure?
Past Medical History (PMH)
• Chronic conditions: HTN, diabetes, hyperlipidemia, migraines, autoimmune disorders.
• Neurologic history: prior stroke/TIA, neuropathy, seizures.
• Musculoskeletal history: cervical radiculopathy, rotator cuff issues.
Medications
• Antihypertensives, statins, anticoagulants, steroids, immunosuppressants
• Over-the-counter meds or supplements
, Allergies
• Drug, food, environmental — include reactions.
Family History (FH)
• Stroke
• Multiple sclerosis
• Muscular dystrophy
• Peripheral neuropathy
• Autoimmune disease
Social History (SH)
• Tobacco/alcohol/drug use
• Occupation involving repetitive upper-extremity tasks
• Exercise habits
• Recent travel
• Living situation and ADL independence
Review of Systems (Focused ROS)
Neurologic:
• Weakness, numbness, tingling
• Headache, dizziness
• Speech or gait changes
Musculoskeletal:
• Arm pain, shoulder/neck pain
• Loss of range of motion
• Swelling
General:
• Fever, weight changes, fatigue
encounter ARM WEAKNESS with a full SOAP
NOTE REAL!!! 2025 NEW!!!
Week 3 I-Human Case | Reason for Encounter: Arm Weakness – History
Chief Complaint (CC)
“My arm feels weak.”
Patient presents with new-onset weakness of the ____ arm (left/right—fill in based on your case).
History of Present Illness (HPI)
• Onset: When did the arm weakness begin? Sudden or gradual?
• Location: Entire arm vs. specific area (shoulder, forearm, hand).
, • Duration: Continuous or intermittent?
• Characteristics:
o Difficulty lifting objects?
o Trouble with grip strength?
o Any numbness, tingling, or pain?
o Any dropping of objects?
• Associated Symptoms:
o Headache
o Facial droop
o Speech difficulty
o Vision changes
o Neck pain
o Recent viral illness
• Aggravating/Relieving Factors:
o Movement, rest, neck movement, overhead activities, repetitive use.
• Severity: Impact on ADLs (buttoning shirt, writing, carrying items).
• Context:
o Any trauma, fall, sports injury, or heavy lifting?
o Recent vaccination or injection?
o Recent illness, fever, or tick exposure?
Past Medical History (PMH)
• Chronic conditions: HTN, diabetes, hyperlipidemia, migraines, autoimmune disorders.
• Neurologic history: prior stroke/TIA, neuropathy, seizures.
• Musculoskeletal history: cervical radiculopathy, rotator cuff issues.
Medications
• Antihypertensives, statins, anticoagulants, steroids, immunosuppressants
• Over-the-counter meds or supplements
, Allergies
• Drug, food, environmental — include reactions.
Family History (FH)
• Stroke
• Multiple sclerosis
• Muscular dystrophy
• Peripheral neuropathy
• Autoimmune disease
Social History (SH)
• Tobacco/alcohol/drug use
• Occupation involving repetitive upper-extremity tasks
• Exercise habits
• Recent travel
• Living situation and ADL independence
Review of Systems (Focused ROS)
Neurologic:
• Weakness, numbness, tingling
• Headache, dizziness
• Speech or gait changes
Musculoskeletal:
• Arm pain, shoulder/neck pain
• Loss of range of motion
• Swelling
General:
• Fever, weight changes, fatigue
