NURSING > CASE STUDY > Rheumatoid Arthritis SOAP Note (All)

Rheumatoid Arthritis SOAP Note

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CL, 7-year-old male brought to the clinic by the father. Referral: None Source and Reliability: Father, medical history. S (Subjective): Chief Complaint: My son has been complaining of pain in his fingers, elbows, and neck. I fear that he could be having rheumatoid arthritis. HPI: It has been a privilege having the patient in the pediatric clinic who has been brought by the father with the complaint of joint pain for the past one month. The patient has been healthy all through and does not have a history of any systemic disease until two months ago when he started complaining of pain in the neck, elbows, and fingers. He cries most of the times since the pain is too much for him to bear. He rarely complains and is always active, carrying out all the duties on his own. He father indicates that there has been mild swelling of the elbows and fingers. The father denies an incidence of diarrhea, fevers, mouth ulcers, weight gain or loss, lymphadenopathy, stomach pain and urinary problems. PMH: Allergies: Seasonal allergies. Not allergic to drugs. Current Medication: Motrin to relieve pain and Claritin for rhinitis and seasonal allergies. Immunizations: Fully updated. Previous Routine Tests: Has been to the clinic for dental assessment. Past Illnesses: None Hospitalizations: None Birth History: There were no complications during delivery and in the course of the pregnancy and was delivered at full term through normal vaginal delivery. Developmental History: has been growing well without any health complications observed. Family History: The mother and father are all alive with the mother healthy while the father has once suffered from psoriasis. The grandmother also has arthritis. The grandfather died of food poisoning but also suffered from arthritis. Social History: Lives with both parents and his elder sisters. The siblings are all healthy without any health complications. They rear 4 cats, 5 dogs and 3 mules. He is in grade two and participates in exercises without any complexities. ROS: Constitutional: The patient appears healthy and denies body weakness, night sweats, weight changes, fever, and fatigue. HEENT: Denies light headedness or injuries. Denies poor vision or eye dryness. Hearing has no impairment, vertigo, tinnitus and discharge. Patient denies nosebleeds, itching, stiffness of the nasal mucosa or sinus congestion. Denies sore throat, hoarseness, sore tongue or mouth dryness. ...........................................Continued.....................................

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