SOAP NOTE Rheumatoid Arthritis. Study Guide.

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, she 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 food. 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 energy level Cardiovascular Denies chest pain, palpitations, PND, orthopnea, edema