SOAP NOTE Rheumatoid Arthritis SOAP NOTE Name: C.M. Date: 04/08/2016 Time: 10:55 Pt. Encounter # Age: 52 Sex: Female SUBJECTIVE CC: “My hands are swollen and painful” HPI: This is a 51 -year-old female who comes to the office with complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. Also, sh e report weight loss, anorexia, aching, and stiffness. Morning stiffness lasts for as long as 1 to 2 hours. Medications: 1. Diovan 80mg po daily 2. Singular 10mg po at bed time 3. Tylenol 500mg 1 tab po every 6 hours x pain 4. Albuterol 2 puff every 6 hours as needed PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas : Hypertension, Asthma. Hospitalizations/Surgeries : Hysterectomy 5 years ago. Family History Mother diagnosed with: Asthma, Hypothyroidism, Rheumatoid Arthritis Father diagnosed with: HTN, Dementia Sister diagnosed with: HTN Social History Patient has a high school education. She works as a mail carrier for the post office for 15 years. She has been widowed for the last two years. Currently, she lives alone in a rented apartment. She has two living children, who all live close by and have families of their own. She reports her family is supportive and denies any needs at this time. She has adequate shelter and fo od. She denies any leisure activities. She refuses to practice exercises. She just goes to the local church on Sunday. She eats a diet low sodium. She denies substance use, ETOH, tobacco, marijuana or illicit drugs. ROS General Weight loss and fatigue Decreased e nergy level Cardiovascular Denies c hest pain, palpitations, PND, orthopnea, edema Skin Denies d elayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Denies c ough, wheezing, dyspnea at this time Eyes Corrective lenses Gastrointestinal Denies a bdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Denies e ar pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Denies u rgency, frequency bu rning, change in color of urine, vaginal discharge or STDS . Hysterectomy 5 years ago. Last mammo graphy 1 years ago. G2, P2, A0 Nose/Mouth/Throat Denies s inus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion. Breast SBE every month , denies lumps, bumps or changes Neurological Denies s yncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies d epression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight : 139 BMI : 23.9 Temp : 98.2 BP: 127/79 Height: 5’4 Pulse : 84 Resp : 16 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Skin Skin is white , warm, d ry, clean and intact. No rashes . HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No
