Meagan Mullany, BSN, RN NUR 6121-800 SOAP Note: Musculoskeletal
Patient: Shoshanna Tillman
SUBJECTIVE CC: “I’m here to follow up on my last visit about my joint pain and how tired I am.”
HPI: Shoshanna Tillman is a 39-year-old female who presents to the clinic complaining of fatigue and joint pain. The joint pain is constant and started 3 months ago. The pain is mostly in her hands and wrists. The patient also complains of generalized pain. Pain is worse in the morning. The patient complains of dull, throbbing, and stiff pain in the wrists and hands. The full body pain is described as stiff and achy. The patient states her current pain is 2 out of 10. Mrs. Tillman says that hot showers and Diclofenac helps decrease the joint pain. If she uses her hands for a long period of time, there is an increase in joint pain. The patient also states that sitting too long also irritates her joint pain. Prior to Diclofenac, the pain is rated as a 3 or 4 out of 10. The fatigue is constant and started 3 months ago. There are no aggravating or relieving factors for the fatigue. The fatigue gets worse as the day goes on. The patient also complains of being intermittently feverish, decrease appetite, and weight loss for the past month. Patient can complete her activities of daily living without pain, but states that she feels “drained” after and it takes longer than usual.
PMH: Denies medical history. Denies mental health conditions. Denies environmental hazards. Denies recent travel.
Past Surgical History: Denies surgical history. The patient has only been hospitalized for her three deliveries.
Medications: Diclofenac sodium 50 mg Q12H PRN pain Ibuprofen 400 mg Q8H PRN pain (discontinued) IUD levonorgestrel, last replaced 24 months ago
Allergies: Codeine allergy (rash, itching) Denies allergies to environment, pets, food, medications, or latex.
Immunizations: Up to date, including influenza
Family History: Mother (67) living with no known or reported medical issues. Father (68) living with no known or reported medical issues. Brother (34) living with no known or reported medical issues.
Social History: Denies tobacco use, denies illicit drug use. Patient reports social alcohol use, 1-2 times a week with no more than 2 drinks in one sitting.
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Physical activity – Walks dog 3-4 times a week, patient stopped going to yoga and spin classes due to fatigue Sleep – Reports 5-6 hours a night Nutrition – Regular, balanced diet Hydration – Drinks 6-8 glasses of water per day Social support – Strong network of friends and family. Patient lives in a single-family home with her husband, three children, and golden retriever. Occupation – Owns and operates an art gallery, obtained a BFA in studio art and BA in art history, patient states she makes enough to support her family but worries about having a “bad month”
ROS General: Denies chills and malaise. Reports feeling feverish intermittently but does not take temperature. Reports fatigue. Resp: Denies shortness of breath, cough, wheezing. CV: Denies chest pain, palpitations, or swelling. Integumentary: Denies rash, sores, itchiness. Denies hair loss. Denies changes in nail pigment or contour. GI: Denies abdominal pain, nausea, vomiting, diarrhea. Reports loss of appetite and weight loss. Reports losing 4-5 pounds over the last month. Reports eating smaller portions of meals. MSK: Denies injury or decrease in range of motion. Denies pain with movement. Neuro: Denies headache, weakness, dizziness, tingling, numbness. Psych: Reports feeling sad for the past 2-3 weeks due to joint pain. Reports feeling anxious for the past 2-3 weeks.
OBJECTIVE Vital Signs: BP 128/78 HR 86 SpO2 99% RR 20 Temp 36.7
ASSESSMENT CV: S1, S2 auscultated. No extra sounds. No murmurs, rubs, clicks, or gallops. Heart rate is regular. Respiratory: All area clear with no adventitious sounds present. HEENT: Both eyes normal with white sclera. No visible abnormal findings. Conjunctiva moist and pink with no discharge present. Mouth is moist and pink. Thyroid with no nodules, not enlarged, no irregularities or tenderness reported. Integumentary: Hair, skin, and nails with no visible abnormal findings. MSK: Hands and wrists with no visible abnormal findings. Lower extremities with no visible abnormal findings. No abnormal findings in left or right upper extremities. No abnormal findings in left or right lower extremities. PIP joints tender bilaterally. Radial pulses +2 bilaterally.
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Finkelstein’s test negative bilaterally. Tinel’s test negative bilaterally. Phalen’s test negative bilaterally. OK test negative bilaterally. Range of motion 5/5 bilaterally on upper extremities. Squeezing strength 5/5 bilaterally on upper extremities. Pushing strength 5/5 bilaterally on upper extremities. Expected sensation in hands and feet bilaterally.
Primary diagnosis: M 25.50 Joint pain, unspecified This patient has joint pain and the specific tests run so far have been negative.
Differential Diagnosis: M 10.9 Gout, unspecified Gout usually presents with joint pain, swelling, and warmth. (Buttaro et al., 2021) Fatigue, fever, and chills can also accompany signs and symptoms of gout. (Buttaro et al., 2021) Diagnosis of gout is usually confirmed by needle aspiration to see if there is MSU crystals present. (Buttaro et al., 2021)
M06.9 Rheumatoid Arthritis Initial symptoms include weight loss, anorexia, aching, stiffness, and fatigue. (Buttaro et al., 2021) Localized symptoms include painful, tender, and swollen joints. (Buttaro et al., 2021) Morning stiffness and joints of the hands and wrists are also factors in the presentation of this disease. Buttaro et al., 2021) In order to diagnose Rheumatoid Arthritis, an ESR, CRP, anti-CCP, CBC, hepatic panel and serum creatinine should all be run. (Buttaro et al., 2021)
PLAN Pharmacologic – Renew prescription for Diclofenac 50 mg Q12H PRN pain.
Non-Pharmacologic – Encourage heat therapy, exercise such as yoga, massage, heat applied to joints (Hollier, 2021)
Education – Educate on side effects of Diclofenac such as constipation, diarrhea, loss of appetite, heartburn, bloating, increased bleeding time, edema, headache, rash/itchy skin, and tinnitus. (Hollier, 2021)
Referrals – No need for referral currently. However, physical therapy may be warranted if patient develops decreased strength or range of motion. (Hollier, 2021)
Follow-Up – See back in clinic in 2-4 weeks and as needed for increased joint pain, disability, or decreased range of motion. (Hollier, 2021)
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References
Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., Trybulski, J. A., & Distler, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier.
Hollier, A. (2021). Clinical guidelines in primary care (4th ed.). Advanced Practice Education Associates.
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