SOAP Note Template
Encounter date: 6/21/2023
Patient Initials: JSK Gender: Male Age: 30 Race: Caucasian Ethnicity: Irish
Reason for Seeking Health Care: The patient presented with shortness of breath, joint pain, chest pain, and fatigue
HPI: The patient is a 30-year-old male who presents with shortness of breath, joint pain, chest pain, and fatigue. He has experienced these symptoms for the last two days. The patient reported being exposed to extremely cold outdoor temperatures without appropriate clothing for 8-10 hours two days ago. He denies any history of alcohol or illicit substance use, smoking, physical injury, or exposure to an infectious environment. He lives with his parents in a single-family house and is unemployed.
Allergies(Drug/Food/Latex/Environmental/Herbal): No known allergies
Current perception of Health: Fair
Past Medical History
Major/Chronic Illnesses: Hyperlipidemia, diabetes, depression
Trauma/Injury: None
Hospitalizations: None
Past Surgical History: Appendectomy 4 years ago
Medications: Metolazone 2.5 mg once daily, Atorvastatin 20 mg once daily, Acarbose 50 mg 2 times daily
Family History: Father - diabetes, Mother - Hypertension, Grandfather - Congestive heart failure
Social history:
Lives: Single-family House Marital Status: Single Employment Status: Unemployed Current occupation type: Not Working
Exposure to: No Smoke, No ETOH, No Recreational Drug Use:
Sexual orientation: Heterosexual Sexual Activity: No Contraception Use: No
Family Composition: Lives with parents
Health Maintenance
Screening Tests: Up to date
Exposures: None
Immunization HX: Up to date
Review of Systems:
General: The patient is fatigued with no significant weight loss or weight gain.
HEENT: No sore throat, ear pain, or nasal congestion.
Neck: No lymphadenopathy.
Lungs: Shortness of breath, no wheezing or crackles heard.
Cardiovascular: Chest pain, irregular heartbeats, no edema.
Breast: No masses or nipple discharges
GI: No nausea, vomiting, or diarrhea.
Male/female genital: No genital discharge
GU: No urinary frequency
Neuro: No signs of stroke
Musculoskeletal: Joint pains
Activity & Exercise: Limited due to joint pain
Psychosocial: Mild anxiety
Derm: No skin lesions
Nutrition: Eating regular meals
Sleep/Rest: Poor sleep
LMP: Not applicable
STI Hx: Negative
Physical Exam
BP 110/70, TPR 97.8, HR: 80, RR: 15, Ht. 5'11 Wt. 200 lbs, BMI (percentile) 32.4
General: The patient is afebrile, well-nourished, and appears uncomfortable due to joint pain.
HEENT: Normocephalic, sclera anicteric
Neck: No jugular venous distension, no lymphadenopathy
Pulmonary: Good air entry, breath sounds vesicular, no rales or wheezing.
Cardiovascular: Tachycardia, regular cardiac rhythm, and no murmur.
Breast: No masses or discharge noted.
GI: Positive for mild epigastric tenderness
Male/female genital: Normal male genital exam.
GU: Not applicable
Neuro: Cranial nerves 2-12 intact
Musculoskeletal: The patient has joint pain in the knee with a limited range of motion.
Derm: No skin lesions noted
Psychosocial: Patient appears anxious
Misc.: No evidence of cyanosis or clubbing
This patient presents with various symptomatic complaints related to a cardiovascular issue. The chief complaints involve shortness of breath, joint pain, chest pain, and fatigue. Contribution factors are his age, gender, race, ethnicity, family history, medication usage, and exposure to extremely cold outdoor temperatures. His physical examination revealed tachycardia, regular cardiac rhythm, tachypnea, positive epigastric tenderness, and joint pain in the knee with a limited range of motion. His lab testing and/or imaging results could reveal signs of acute cardiovascular issues that may be causing the reported symptoms.
Plan:
Differential Diagnoses
1. Viral syndrome
2. Myocarditis
3. Pulmonary embolism
Principal Diagnoses
1. Rheumatoid arthritis
2. Uncontrolled hyperlipidemia
Plan
Diagnosis #1 Rheumatoid arthritis
Diagnostic Testing: CBC, ESR, RF, ANA, UA.
Pharmacological Treatment: NSAIDs, Prednisone
Education: Rheumatoid arthritis causes and symptoms, lifestyle modifications, Medication side effects
Referrals: Rheumatology
Follow-up: Follow-up in 2 weeks
Anticipatory Guidance: Activity modifications to reduce joint pain and inflammation.
Diagnosis #2 Uncontrolled Hyperlipidemia
Diagnostic Testing: FBS, Lipid profile
Pharmacological Treatment: Atorvastatin 20 mg daily
Education: Risk factors for heart disease and stroke, dietary modifications, lifestyle modifications, Medication side effects
Referrals: Cardiology
Follow-up: Follow-up in 6 weeks
Anticipatory Guidance: Monitor for signs and symptoms of cardiac events and physical activity.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced-based guideline(s) used to guide care (Mandatory)
Rheumatoid Arthritis, an autoimmune malady, elicits joint inflammation, swelling, stiffness, and pain. The condition in question primarily impacts the joints in the hands and feet, potentially affecting the knees, hips, wrists, and elbows, as the Centers for Disease Control and Prevention noted in 2020. Individuals afflicted with Rheumatoid Arthritis may encounter challenges performing routine tasks, such as inscribing written language, fastening clothing, and unsealing containers. Moreover, it may result in both physical and mental exhaustion and a sense of despondency. The etiology of Rheumatoid Arthritis still needs to be comprehended, albeit plausible, that a confluence of environmental and hereditary determinants may incite the ailment.
The principal objective of therapy is to mitigate inflammation and alleviate discomfort while concurrently fostering enhanced physical functionality. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) advocates for a multifaceted approach to treating Rheumatoid Arthritis, which encompasses a range of interventions such as rest, exercise, education, medication, and surgical procedures as deemed appropriate (NIAMS, 2016; NIAMS, 2017). The pharmacological agents most frequently prescribed for this ailment are nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs), which have demonstrated efficacy in mitigating pain and inflammation. In addition to NSAIDs or DMARDs, certain patients may have access to biological medications for potential therapeutic combinations.
Physical activity constitutes a crucial component of the therapeutic regimen for Rheumatoid Arthritis, given its potential to mitigate pain and stiffness, enhance joint mobility, and promote physical and psychological well-being (CDC, 2022). For optimal outcomes, individuals afflicted with Rheumatoid Arthritis are advised to partake in low-impact exercises, including but not limited to swimming, walking, and practicing yoga and tai chi. Engaging in a dialogue with a physical therapist to formulate a suitable physical activity regimen is of utmost significance.
Acquiring knowledge and skills through formal instruction is crucial in the holistic management of Rheumatoid Arthritis. Individuals must be apprised of the state of affairs, including its etiology, therapeutic modalities, and potential hazards, as posited by Bullock et al. (2018) and Chauhan et al. (2023). Individuals must be well-informed regarding lifestyle modifications that may prove advantageous, including adhering to a nutritious diet, refraining from deleterious habits such as smoking, and restricting alcohol intake.
Surgical interventions such as joint replacement and fusion may be imperative in certain instances. The implementation of these methodologies could enhance joint functionality and mitigate discomfort. Nevertheless, they are frequently reserved for grave instances due to the potential for complications, such as infection.
To succinctly encapsulate, Rheumatoid Arthritis is a persistent ailment that may result in joint rigidity, discomfort, and incapacitation. The therapeutic regimen encompasses pharmacological agents such as nonsteroidal anti-inflammatory drugs and disease-modifying antirheumatic drugs, physical activity, enlightenment, and operative procedures if deemed essential. The primary objective of the therapeutic intervention is to mitigate discomfort, enhance operational capacity, and forestall any additional harm to the articulations. By employing an optimal amalgamation of therapeutic interventions, individuals afflicted with Rheumatoid Arthritis may experience an enhanced quality of life characterized by increased engagement in physical and social activities.
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)JSK Age 30
Date: 6/21/2023
RX Metolazone 2.5 mg once daily, Atorvastatin 20 mg once daily, Acarbose 50 mg 2 times daily
SIG:
Dispense: 30-day supply Refill: 2 refills
No Substitution
Signature: ____________________________________________________________
References
Bullock, J., Rizvi, Syed A. A., Saleh, Ayman M., Ahmed, Sultan S., Do, Duc P., Ansari, Rais A., & Ahmed, J. (2018). Rheumatoid arthritis: A brief overview of the treatment. Medical Principles and Practice, 27(6), 501–507. https://doi.org/10.1159/000493390
CDC. (2022, January 5). Physical Activity for Arthritis | CDC. Www.cdc.gov. https://www.cdc.gov/arthritis/basics/physical-activity/index.html
Centers for Disease Control and Prevention. (2020, July 27). Rheumatoid Arthritis (RA) | Arthritis | CDC. Www.cdc.gov. https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html#:~:text=Rheumatoid%20arthritis%2C%20or%20RA%2C%20is
Chauhan, K., Jandu, J. S., & Al-Dhahir, M. A. (2023, January 10). Rheumatoid Arthritis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441999/
NIAMS. (2016). National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Nih.gov. https://www.niams.nih.gov/
NIAMS. (2017, April 20). Rheumatoid Arthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/rheumatoid-arthritis