01_29_2024 SOAP note

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University of Utah *

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MISC

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Medicine

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Feb 20, 2024

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docx

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Tutorials Spring 2024 SOAP Note (1/29/2024) Gabriella Jones, PA-S CA: Melanie Access Medicine: Bone spurs in both hands and right foot Patient: D. Smith Age: 53 Language: English Sex at birth: Female Source of hx: Patient Reliability: Seems reliable CC: Bone spurs on hands Present illness: DS presented to the clinic for concern of bone spurs on both hands. Pt said she started noticing hard bone spurs that have “appeared over time” on the Distal Interphalangeal joint of the right hand fifth digit, and the left hand second digit distal interphalangeal joint. Nodules have mild tenderness to palpation but denies erythematous or swelling. Denies decrease range of motion. Denies any wrist pain. Patient said they do not interfere with her life. Pt came in for concern of either Rheumatoid Arthritis or Osteoarthritis. Denies morning stiffness, or any family history of Rheumatoid Arthritis. Denies the use of any medications for treatment of nodules. Denies decrease in activities of daily living. Denies any other joint swelling, stiffness, or erythema. Past Medical History: Childhood/Adult Illnesses: Childhood illness: Not addressed this visit. Denies measles, mumps, rheumatic fever, CVD, murmur, HTN, hyperlipidemia, stroke, DVT, transfusions, cancer, TB, DM, STI, thyroid disease, asthma, arthritis, dementia, OSA, addictions, epilepsy, depression, anxiety, history of any form of abuse, eating disorders. Hospitalizations/Injuries/Surgeries: - Denies any other hospitalizations, surgeries, or injuries Drugs and environmental allergies: - Allergy to Phenergan – reaction: muscle spasms - Denies any significant environmental allergies Current/Recent Medications: Denies any current meds - med reconciliation on 1/25/2024

Denies supplements, OTC, or vitamins. Health Maintenance: Immunization status: Not addressed this visit. Screening Tests: Not addressed this visit. Occupational & Environmental Exposures: Not addressed this visit. Family History: Relative Age/Gender Status Mother (Age not given on chart) Health history not given on chart Father (Age not given on chart) Health history not given on chart Child (Age not given on chart) History of seizures Denies family history of stroke, HTN, hyperlipidemia, cancer, tuberculosis, thyroid disease, arthritis, asthma, addictions, epilepsy, depression, anxiety, or other recurring diseases. Social History: Alcohol/Tobacco/Drugs: Denies the use of drugs or alcohol Recreation/Exercise: Exercises for 30 mins, 3 times per week Educational history, occupational history, diet, caffeine intake, and living situation: did not address this visit. ROS: General: Denies weight or appetite changes, fatigue, fever, chills, or night sweats. Skin: Denies pruritus, rash, skin changes. HEENT: Denies vision changes, corrective lenses, diplopia, or blurring. Denies hearing loss, tinnitus, and ear pain . Denies nasal congestion and epistaxis. Denies for sore throat, hoarseness, dental problems, dentures, or neck swelling. Cardiopulm: Denies exercise intolerance change, wheezing, chest pain, palpitations, claudication, syncope, hemoptysis, dyspnea, orthopnea, PND, or edema. MSK: See HPI. Denies swelling, stiffness, back pain, or difficulty with ADLs. Endo: Denies temperature intolerance, weight change, menstrual changes, skin, hair, or voice change. Denies polydipsia and polyuria. Objective: Vitals: HR 91, O2 sat 99% on RA, BP 106/61 mmHg, Ht 160 cm, Wt 65.7 kg, BMI: 25.6, Temp and RR not given

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