NURSING 650 Week 3 SOAP note_ Summer 2020/2021

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NURSING 650 Week 3 SOAP note SUBJECTIVE DATA IDENTIFYING DATA Initials: L. Age: 56 Race: Caucasian Gender: Female Marital Status: In a monogamous relationship Source: Patient – appears to be a relia... ble source of information, alert and orients to person, place, time, and situation; ready recall and understanding of medical HX CHIEF COMPLAINT : “I reinjured my shoulder in November and it still isn’t healed.” HISTORY OF PRESENT ILLNESS: O Patient reports injury occurred in November when she was on a ladder that started to tip; when her arms swung up to catch herself, she hit her R shoulder on scaffolding and felt a pop in her shoulder. Patient also reports that she had an injury to her R shoulder when she was 17 (separation) and it took 10 years to heal. L The patient reports the majority of her pain occurs in her R trapezius and deltoid. She says pain also radiates down her are to her R ring and pinky fingers. D She reports the pain is constant but increase and decrease in severity throughout the day based on her activity level. C At a base line she reports a dull pain 3/10 but reports certain movements can lead to a sharp pain 10/10. A The patient movements that include lifting or moving her arm when full extended aggravate her injury. Resting her arms to work (typing at a computer) on a surface that is too high aggravates her shoulder. The patient reports that she can sleep on her back comfortably but sleeping on either side also causes an increase in pain. T First thing in the morning the patient reports her pain is typically dull and her pain increases in severity throughout the day. R Immobilization provides the patient with the most relief. She has been doing exercises her chiropractor gave her and she thinks these are helping. In the evening her partner massages the should with a CBD rub and the patient says this helps her sleep. This injury has limited the patient in daily physical activity since November. She has adjusted her workstation and exercise practices to accommodate her injury. After days when she “over does it” she says she “can’t do anything” the next day. This is also affecting her relationship with her partner who feels the patient isn’t “helping out” enough. PAST MEDICAL HISTORY: • Allergies: NKA/NKDA • Current medications: Estradiol weekly transdermal patch 0.05mg; Progesterone 200 mg capsule daily; Meloxicam 15 mg tab daily; daily multivitamin; Vitamin e supplement (unsure of dosage) • Age/health status: 56 years • Appropriate immunization status: Current on all vaccines; Flu vaccine fall 2019. • Health maintenance: Patient reports daily exercise of at least 30 minutes a day and is proud of her 238 day “streak”. Reports eating healthy meals, making and keeping regular well-patient exams and screenings. Her last physical and mammogram were last fall (2019). She says she also had labs drawn at that time and they were all “good”. [Show More]

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