MUSCULOSKELETAL TINA JONES SOAP
S.O.A.P. Note Template CASE ID# Tina Jones Musculoskeletal Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
What brought you here today (eg. headache)
“I have a lot of...
MUSCULOSKELETAL TINA JONES SOAP
S.O.A.P. Note Template CASE ID# Tina Jones
Musculoskeletal Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
mplaint Chief
What brought you here
“I have a lot of pain in my lower back.”
today (eg. headache)
shared via
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
This study resource
paragraph form
Onset Patient is a 28-year-old African American woman who presented to the
Location clinic complaining of back pain that began 3 days ago. She states she
CourseHero.com
Duration “tweaked it” while lifting a heavy box. She states that lifted several boxes
was
Character
to help her friend who was moving, she does not know the weight of the
Aggravating/associate
d factors box that caused her pain. She states the pain is in her low back and bilateral
Relieving factors buttock. She describes the pain as constant aching with stiffness but does
History
Present
Illness
Temporal factors – not radiate. She states the pain is at its worse while sitting, which rates a
of
other things going on 7/10. The pain decreases with rest and lying flat on her back, which she
rates approximately 3-4/10. The pain has not changed over the past three
days She has treated the pain with 2 over the counter ibuprofen tablets
every 5-6 hours. She states the ibuprofen can decrease her pain to 2/0. Her
Severity current pain is a 5/10. She denies numbness, tingling, muscle weakness,
bowel or bladder incontinence. She denies neck pain. She denies any
history of back of neck pain. She denies history of trauma or accidents. She
reports that pain is interfering with her sleep and activities of daily living.
Adult Illnesses,
Medical
History
childhood illnesses, Adult illness: diabetes, asthma
Past
immunizations, Childhood illness: asthma at 2.5 years old
surgeries, allergies, Immunizations: up to date, received annual flu shot
Include Parents, Mother: Alive 59 y.o., High blood pressure, high cholesterol
History
Family
siblings; grandparents Father: Deceased at 58 due to car accident Type II Diabetes, high
if applicable/known, blood pressure, high cholesterol
cause of death, age, Paternal grandmother: Alive 84 y.o., High blood pressure, high cholesterol
, Education, marital
Personal/Social status, occupation, Education: Current Student
History alcohol/drug use, Marital Status: Single
Occupation: supervisor at Mid-American Copy and Ship
smoking status, sexual
Religion: Christian
history if relevant, Social History: Denies drug use, non-smoker, denies vaping,
exercise, nutrition, social drinking- no more than 4 drinks a month
This study source was downloaded by 100000815376421 from CourseHero.com on 04-01-2021 15:04:35 GMT -05:00
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