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Musculoskeletal soap note

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Running head: MUSCULOSKELETAL SOAP NOTE 1 Musculoskeletal Soap Note Patient Initials: Jackeline Washington Age: 30 Gender: Female Ethnicity: African Chief Complaint (CC): Joints ache, hard to d ... o her daily chores around the house. History of Present Illness (HPI): The patient is a 30-year-old female who complains of pain in the joints, mostly in her bilateral fingers and wrists. She has experienced this for the past month but has progressively deteriorated. She declares that she feels intense pain in the a.m. and often feels stiff, and it has made her have a tough time doing her household chores. Besides, she indicates that the stiffness/pain relieves as the day passes by. The patient asserts that her pain level is 9/10 in the a.m. and lessens to a 3/10 in the afternoon. The patient is currently consuming OTC Tylenol and OTC ibuprofen for the pain but asserts that it is not effective in alleviation most of the time. She indicates that the morning pain feels like aching/stiff/throbbing lasting approximately three to four hours. She adds that her hands feel and look swollen occasionally. Current Medications: Multi-Vitamin OTC Tylenol 500mg OTC ibuprofen 800mg Victoza 1.8mg SC once daily Metformin 500mg PO once daily Allergies: Seasonal allergies Past Medical History (PMH): 1.) Diabetes type 2 Past Surgical History (PSH): RT toenail extraction-Ingrown toenail [Show More]

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