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Meagan Mullany, BSN, RN NUR 6121-800 SOAP Note: MusculoskeletalPatient: Shoshanna TillmanSUBJECTIVE CC: “I’m here to follow up on my last visit about my

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.

This study source was downloaded by 100000760925736 from CourseHero.com on 02-24-2024 12:18:22 GMT -06:00

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