SOAP NOTE

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 complains 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

Social History

Patient has a high school education. She works as a mail carrier for the post office for 15 years. She has been widowed for the last two years. Currently, she lives alone in a rented apartment. She has two living children, who all live close by and have families of their own. She reports her family is supportive and denies any needs at this time. She has adequate shelter and food. She denies any leisure activities. She refuses to practice exercises. She just goes to the local church on Sunday. She eats a diet low sodium. She denies substance use, ETOH, tobacco, marijuana or illicit drugs.

ROS

General

Weight loss and fatigue

Decreased energy level

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, edema

Skin

Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Denies cough, wheezing, dyspnea at this time

Eyes

Corrective lenses

Gastrointestinal

Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears

Denies ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine, vaginal discharge or STDS. Hysterectomy 5 years ago. Last mammography 1 years ago.

G2, P2, A0

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Musculoskeletal

Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion.

Breast

SBE every month, denies lumps, bumps or changes

Neurological

Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo

Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight:  139     BMI: 23.9

Temp: 98.2

BP: 127/79

Height: 5’4

Pulse: 84

Resp: 16

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Skin is white, warm, dry, clean and intact. No rashes.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed.

Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection.

Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized.

Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen flat; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. 

Breast

Deferred.

Genitourinary

Bladder is non-distended; no CVA tenderness.

External genitalia: deferred

Musculoskeletal:

The wrists and small joints of the hands (metacarpophalangeal and proximal interphalangeal joints) are swelling, with deformity and limed range of motion. The skin over the affected joint look thin and shiny and have a ruddy color. Joint involvement is bilateral and symmetric. On palpation, the inflamed joint feels warm and tender and the synovial membrane feels thickened and boggy. Subcutaneous nodules over extensor surface of the elbow

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

1. CBC: Normocytic, normochromic anemia is common in RA

2. Urinalysis

3. Serum creatinine and Hepatic panel: Evaluation of renal and hepatic functions is necessary because many antirheumatic agents have renal and hepatic toxicity and may be contraindicated if these organs are severely impaired

4. Acute-phase reactants are proteins that are synthesized rapidly by the liver in the presence of inflammation or tissue necrosis and include CRP, fibrinogen, complement proteins, and several other proteins. Measurement of serum concentration of CRP and ESR is widely used to assess the activity of the inflammatory process and to aid in monitoring of the response to therapy,

5. RF in RA is an immunoglobulin M autoantibody that is directed against antigenic determinants in the immunoglobulin G molecule. Not all RA patients have a positive test result for RF at the time of diagnosis, but the result will become positive for 70% to 80% of patients during the course of disease

6. Anti-CCP antibodies

7. X-ray studies of affected joints help with the diagnosis and establish a baseline for future evaluation of the effectiveness of treatment. The radiographs of the joints and bones are often normal at the onset of the disease, but bone erosions can develop within the first years.

8. Magnetic resonance imaging (MRI) is increasingly used to confirm the diagnosis of RA; bone marrow edema is a hallmark finding in early RA. The American College of Rheumatology has established criteria for the classification of RA that can be used as guidelines for patient diagnosis and for research classification Radiography of selected involved joints MRI.

9. Synovial fluid analysis

Diagnosis

Differential Diagnoses

1. Fibromyalgia

2. Osteoarthritis

3. Systemic lupus erythematosus

Diagnosis

· Rheumatoid Arthritis (suspected)

Plan/Therapeutics

Plan:  The standard goal of RA management is remission or low disease activity.

Medication:

Pharmacologic therapy most often consists of combination therapy, synthetic and biologic disease-modifying antirheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids (GCs)

Our patient is pending for lab test result, the symptomatic treatment for her is

· Diclofenac (NSAIDs): 50 mg po tid

· Prednisone (glucocorticoids): 7.5 mg po am daily

Pending lab result for referral to Rheumatology consultant and treatment with DMARDs

Methotrexate (MTX) is a highly effective drug for disease modification. It is more effective at higher weekly doses (20 to 30 mg) than at lower doses and should be part of the first treatment strategy because it can be used as monotherapy, it increases the efficacy of biologic DMARDs when it used in combination, and it has a long-term safety profile

Education:

1. Patients should be educated about lifestyle modifications, such as increased rest for disease flare-ups, use of adaptive aids to facilitate function, prioritizing and planning of activities to accommodate fatigue, and use of splints for painful and swollen wrists and hands.

2. Consultation with occupational and physical therapists for assistive and adaptive devices and education about care of joints are recommended.

3. Education about the need for a regular aerobic and muscle-strengthening exercise program is essential to help reduce stiffness, to avoid joint contractures, and to prevent osteoporosis.

4. Podiatric care for foot pain should be provided, along with special shoe wear and flexible orthotic devices.

5. The health care provider should advise the patient about the benefit of warm showers in the morning and frequent position changes to alleviate stiffness.

6. The use of pillows to position joints at night is contraindicated because this may predispose the patient to flexion deformities.

7. The health care provider should also educate the patient and family about medication use, restrictions, and side effects or adverse effects.

8. Warnings against stopping of certain medications without notifying the health care provider should be stressed.

9. Instructions should be given about dietary restrictions or recommendations as they relate to medications.

10. Self-management programs, educational information, and exercise programs from the Arthritis Foundation are available to the patients in print form and online. Most material is available in Spanish and English.

Non-medication treatments:

1. Nonpharmacologic measures, such as physical therapy, occupational therapy, and psychological interventions, aid in achieving the goal. Regular participation in dynamic and aerobic conditioning exercises improves joint symptoms, muscle strength, functional abilities, and psychological well-being.

2. Instruction in joint protection, conservation of energy, strengthening exercises, and a range of motion program is beneficial for all RA patients. Complementary and alternative therapy is of growing interest and use to RA patients.

3. Many patients receiving conventional medical therapy are also using acupuncture, acupressure, herbs, and other complementary modalities.

Reference:

Buttaro, Terry, Trybulski, J., Bailey, P., Sandberg-Cook, J. (2013). Primary Care, 4th Edition. [VitalSource Bookshelf Online]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/

Grossman, S., & Porth, C. M. (2013). Porth's Pathophysiology: Concepts of Altered Health

States, 9th Edition. [VitalSource Bookshelf version]. Retrieved from

http://digitalbookshelf.southuniversity.edu/books/9781469871639/id/F61-27

Woo, T. M. & Wynne, A. L. (2011). Pharmacotherapeutics for nurse practitioner prescribers. (3rd ed.). Philadelphia, PA: F.A. Davis Co.