SOAP NOTE ON ANY COMPLICATED DIAGNOSIS (Coursework Sample)

SOAP Note on Rheumatoid Arthritis Student’s Name Institutional Affiliation Author Note SOAP Note on Rheumatoid Arthritis Subjective: CC: “I have been experiencing pain in the elbows, neck and fingers for the past three weeks.” HPI: The 33-year-old patient visits the clinic complaining of pain in the joints that has lasted for three weeks. He indicates that he has been healthy all through and has not suffered from any chronic conditions. He indicates that the pain started mildly and has been persistent especially early in the morning and late in the evening and every time that he has a hard task to handle. He alleviates the paint using Ibuprofen that has not been very effective. He carries out his duties effectively during the day. He indicates to have noted some mild swelling of the fingers and elbows for the past week. He denies urinary problems, diarrhea, stomach pain, mouth ulcers, fever, and lymphadenopathy and weight loss/gain. PMH: Allergies: No history for drug allergies. Indicates to have seasonal allergies. Current Medication: Ibuprofen for pain alleviation and Claritin for seasonal allergies and rhinitis. Immunization: Up-to-date Routine Tests: Visited the health facility three months ago for dental and vision assessment. Past illnesses: No history of illnesses at present and during child hood. Hospitalizations: None Surgical History: Does not have a history for any surgeries. Family History: Both parents are alive with the father suffering from psoriasis while the mother is healthy. The grandmother has arthritis while the grandfather died of food poisoning three years ago at 75. The wife and children are all healthy. Social History: He is married to one wife and they live together with their three children. They are actively involved in daily exercises with the wife at their family yard until recently when he developed the pain. He takes a balanced diet each day and makes sure that every meal is complete. He is a trained IT expert offering services in a leading firm. He does not have a history of smoking or using illicit drugs. He is a Christian and attends church services occasionally. ROS: Constitutional: The patient is generally healthy with no fever, weight changes, fatigue, night sweats and body weakness. HEENT: Head is symmetric with no injuries or lightheadedness. Denies dryness in the eyes and poor vision. Patient denies discharge from the ears, vertigo, tinnitus and visual impairment. Denies incidences of sinus congestion, nasal mucosa stiffness, itching and nose bleeding. Patient indicates no incidences of dryness in the mouth, tongue sores, hoarseness and sore throat. Cardiovascular: Denies chest pain, nocturnal dyspnea, heart troubles, edema, orthopnea and hypertension. Respiratory: Denies wheezing, dyspnea, sputum and coughing. Gastrointestinal: Denies abdominal pain, swallowing troubles, loss of appetite, bowel movement changes and heartburn. Genitourinary: Denies supra-pubic pain, masses, hematuria, scrotal or testicular pain, dysuria, lumps, incontinence and itching. Musculoskeletal: The patient indicates that he feels pain in the elbows, fingers and the neck. Integumentary: Denies changes in the skin, hair and nails. Endocrine: Denies temperature intolerance, excessive sweating, hunger or thirst. Psychiatric: Patient denies incidences of sleep disturbances, depression, anxiety, headache and stress. Objective: General: The patient is neat, well-oriented, responsive and responds to all the questions directed to him. Constitutional: Wt: 147lbs, RR: 20, Temp: 98.40F, BP: 120/64, HR: 72, Ht: 5’4” Head: No facial bruises and rashes on the head. Eyes: No visual impairment and have light sensitivity. Ears: No discharge. Ear canals are clear. Nose: No sinus congestion, nasal mucosa stiffness, itching and bleeding. Mouth/Throat: No sore throat, sore tongue, dry mouth and hoarseness. Cardiovascular: Audible S1 and S2. No asymmetries, cyanosis and palpitations. Respiratory: Unlabored breathing. No sputum, cough, dyspnea and wheezing. Gastrointestinal: No changes in the appetite, bowel habits and swallowing. No abdominal pain and heart burn. Genitourinary: No supra-pubic pain, masses, hematuria, scrotal or testicular pain, dysuria, lumps, incontinence and itching. Musculoskeletal: Pain present in elbows, neck and fingers. No muscle swelli...