musculoskeletal disordersWeek 8 Musculoskeletal Disorders Various treatment options including medications, labs and x-rays for common Musculoskeletal disorders Evaluate pattern recognition, including age, risk factors, and ethnicity in patient Musculoskeletal diagnoses Differential diagnoses for patients with Musculoskeletal disorders Osteoarthritis Rheumatoid arthritis Myasthenia gravis Juvenile Rheumatoid arthritis Gout Patellar fasciitis Cruciate ligament tear Osgood-Schlatter disease Acute back pain Spondylolithiasis Bursitis Radial tunnel syndrome Ulnar collateral ligament sprain Olecranon bursitis Lateral epicondylitis Carpal tunnel syndrome Tarsal tunnel syndrome Ulnar tunnel syndrome Myofascial pain syndrome Ankle sprain Osteomyelitis Muscular dystrophy Scoliosis Septic arthritis Fibromyalgia Comprehensive SOAP Exemplar Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise. Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and fever, physical History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed 6.) Over-the-counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs – rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet, on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: Heterosexual G1P1A0 Non-menstruating – TAH 1998 Personal/Social History: She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. She received
