{"id":465,"date":"2020-02-23T17:06:20","date_gmt":"2020-02-23T17:06:20","guid":{"rendered":"https:\/\/papersspot.com\/blog\/?p=465"},"modified":"2020-02-23T17:06:20","modified_gmt":"2020-02-23T17:06:20","slug":"soap-note","status":"publish","type":"post","link":"https:\/\/papersspot.com\/blog\/2020\/02\/23\/soap-note\/","title":{"rendered":"Soap note"},"content":{"rendered":"\n\n\n\n\n\n\n
<\/td>\nICD #1 –<\/strong><\/td>\nM25.569\u00a0– PAIN IN UNSPECIFIED KNEE<\/td>\n<\/tr>\n
<\/td>\nICD #2 –<\/strong><\/td>\nZ83.2\u00a0– FAMILY HISTORY OF DIS OF THE BLD\/BLD-FORM ORG\/IMMUN MECHNSM<\/td>\n<\/tr>\n
<\/td>\nICD #3 –<\/strong><\/td>\nM05.169\u00a0– RHEUMATOID LUNG DISEASE W RHEUMATOID ARTHRITIS OF UNSP KNEE<\/td>\n<\/tr>\n
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<\/td>\nCPT #1 –<\/strong><\/td>\n99244\u00a0– OFFICE CONSULTATION, 3 KEY COMPONENTS:COMPREHENSIVE HX; COMPREHENSIVE EXAM; MED DECISION MOD COMPLEX<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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WE’VE HAD A GOOD SUCCESS RATE ON THIS ASSIGNMENT. PLACE THIS ORDER OR A SIMILAR ORDER WITH PapersSpot AND GET AN AMAZING DISCOUNT<\/h4>\n

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CC:<\/strong> bilateral knee pain<\/p>\n

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HPI:<\/strong><\/p>\n

Forty-seven years old female, present complaint \u00a0of bilateral knee pain. She states, four days ago, when I was at \u00a0works ( ware house manager ) , and she does 12 hours shift, \u00a0she feels like something broken in her knees. She took Advil 500 mg; it gets better for only 30 min, and the pain started again.\u00a0 She had difficulty sleeping for four nights because of the pain, and she rated the pain\u00a0 8\/10. She said rest makes it better and moving\u00a0 make it worse and also did not go to work for two days, cannot move around the same as before. Redness , stiffness and warmth to touch . the pain is described aching . no back , hip , leg pain . sitting and getting up is painful .<\/p>\n

she has a history of anemia, chest pain ( last year), ruhmitoid arthritis (2 years ago)<\/p>\n

Anemia is running in her family, heart disease and diabetes<\/p>\n

The patient lives with her daughter in a two-bedroom apartment, her daughter in college, and she supported her \u00a0financially.<\/p>\n

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Allergies<\/strong> :<\/p>\n

NKDA<\/p>\n

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Current Medication<\/strong> :<\/p>\n

Advil 200 mg po PRN for pain<\/p>\n

Iron 325mg po three times daily<\/p>\n

Folic acid 5mg po daily<\/p>\n

Norco 5\/325\u00a0 mg\u00a0 PRN\u00a0 as needed if the pain is higher than 4\/10<\/p>\n

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PM HX :<\/strong><\/p>\n

Bilateral knee Arthritis diagnosis 2 months a go<\/p>\n

Hgb 7\u00a0 01\/15\/20\u00a0 hospitalization , blood transfusion<\/p>\n

Colonoscopy\u00a0 10 years ago normal<\/p>\n

Immunization up to date<\/p>\n

Pap smear\u00a0 2019\u00a0 normal<\/p>\n

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Social History :<\/strong><\/p>\n

Divorce on 2000\u00a0 lives with her daughter ( 25 years old\u00a0 college student ). No drink or smoke or illegal drug used .<\/p>\n

\u00a0<\/strong><\/p>\n

Family history :<\/strong><\/p>\n

Parents are alive , dad has heart problem ( CHF) and mom is diabetic<\/p>\n

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ROS:<\/strong><\/p>\n

General<\/strong>: female alert and oriented, cooperative, in no acute distress.<\/p>\n

CV<\/strong>: No reports of chest pain or palpitations<\/p>\n

Respiratory<\/strong>: No reports of shortness of breath or cough<\/p>\n

Musculoskeletal<\/strong>: Reports\u00a0 bilateral knee pain and increased with \u00a0mobility<\/p>\n

Neuro<\/strong>: No reports of numbness, tingling, but \u00a0weakness to extremities<\/p>\n

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WE’VE HAD A GOOD SUCCESS RATE ON THIS ASSIGNMENT. PLACE THIS ORDER OR A SIMILAR ORDER WITH PapersSpot AND GET AN AMAZING DISCOUNT<\/h4>\n

\"\"<\/a><\/p>\n

 <\/p>\n

Objective :<\/strong><\/p>\n

Physical Exam:<\/strong><\/p>\n

Vitals<\/strong>: BP 138\/ 65; HR 73, regular; RR 18, regular; Hgt 5\u2019 2\u201d; Wgt 145 lbs., (60kg);<\/p>\n

General<\/strong>: No acute distress<\/p>\n

HEENT:<\/strong> Eyes \u2013 no drainage, sclera white, wears contacts; Ears – TM gray, intact, with light reflex noted, pinna and tragus nontender; Nose –\u00a0 Nares patent, no drainage; Throat \u2013 oropharynx moist, no redness, Dentition good, no cavities or repair; neck supple, anterior and posterior cervical lymph nontender to palpation, no lymphadenopathy, thyroid midline, small and firm, without palpable masses.<\/p>\n

Skin:<\/strong> Warm dry and intact, no lesions noted<\/p>\n

CV:<\/strong> S1, S2, RRR, no murmurs or rubs<\/p>\n

Lungs:<\/strong> Clear to auscultation bilaterally, no labored respirations.<\/p>\n

Abdomen:<\/strong> Soft, round, nontender, bowel sounds present, no organomegaly, no abdominal bruits, no costovertebral angle tenderness.<\/p>\n

Musculoskeletal:<\/strong> \u00a0pain with range of motion to both knees, nontender to palpitation bilaterally, abnormal \u00a0gait<\/p>\n

Genitourinary:<\/strong> Bladder nontender<\/p>\n

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Assessment :<\/strong><\/p>\n

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Modified diagnostic and impression<\/p>\n

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Assessment of newly developing symptoms<\/p>\n

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Assessment of response to care\/treatment<\/p>\n

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Assessment of functional capacity<\/p>\n

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Stats assessments (acute, chronic, recurrent)<\/p>\n

Bilateral knee pain ,Anemia , chest pain , RA,<\/p>\n

Exam of both knee showed neuro vascular is normal ,\u00a0 decrease ROM in bilateral knee , palpitation of pedal pulses\u00a0 is normal .<\/p>\n

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Plan :<\/strong><\/p>\n

Diagnostics : CBC, CMP , lipid panel , CRP, ESR, anti-CCP<\/strong><\/p>\n

x-ray of both knee \u00a0to rule out fracture or other associated injuries <\/strong><\/p>\n

refill pain medication as needed <\/strong><\/p>\n

refer to physical therapy due to pain and history of RA<\/strong><\/p>\n

Referral to specialist for MRI on both knees \u00a0to assess bilateral soft tissue injuries <\/strong><\/p>\n

Return to clinic in 2 weeks for follow up <\/strong><\/p>\n

Return to work \u00a0after next follow up \u00a0\u00a0<\/strong><\/p>\n

 <\/p>\n

WE’VE HAD A GOOD SUCCESS RATE ON THIS ASSIGNMENT. PLACE THIS ORDER OR A SIMILAR ORDER WITH PapersSpot AND GET AN AMAZING DISCOUNT<\/h4>\n

\"\"<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

ICD #1 – M25.569\u00a0– PAIN IN UNSPECIFIED KNEE ICD #2 – Z83.2\u00a0– FAMILY HISTORY OF DIS OF THE BLD\/BLD-FORM ORG\/IMMUN MECHNSM ICD #3 – M05.169\u00a0– RHEUMATOID LUNG DISEASE W RHEUMATOID ARTHRITIS OF UNSP KNEE       CPT #1 – 99244\u00a0– OFFICE CONSULTATION, 3 KEY COMPONENTS:COMPREHENSIVE HX; COMPREHENSIVE EXAM; MED DECISION MOD COMPLEX   WE’VE […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-465","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/465","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=465"}],"version-history":[{"count":1,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/465\/revisions"}],"predecessor-version":[{"id":466,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/465\/revisions\/466"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=465"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=465"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=465"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}