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 .

1. 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.

2. 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

3. 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

4. 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+

5. 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.

6. 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

7. 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:

8. 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,

9. 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/978146987163
9/id/F61-27
Woo, T. M. & Wynne, A. L. (2011). Pharmacotherapeutics for
nurse practitioner prescribers. (3rd ed.). Philadelphia, PA: F.A.
Davis Co.