NUR 3226L-SOAP NOTE Rheumatoid Arthritis-51 year old female-2022-2023
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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 c... omplains 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 CONTINUED...... [Show More]
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