EPISODIC VISIT: MUSCULOSKELETAL FOCUSED NOTE ESSAY

EPISODIC VISIT: MUSCULOSKELETAL FOCUSED NOTE ESSAY

EPISODIC VISIT: MUSCULOSKELETAL FOCUSED NOTE ESSAY

EPISODIC VISIT: MUSCULOSKELETAL FOCUSED NOTE SAMPLE ESSAY

SOAP Note for Musculoskeletal Issues

Patient Information:

Initials: D.G. Age: 54 years old     Sex: Female Race: African American

Subjective

CC– “Follow-up visit/Physical exam.”

HPI: JD.G., a 53-year-old African-American female, visited today for a one-month follow-up appointment to refill her anxiety medication prescription. The patient was prescribed a daily refill of 1mg of Xanax. The patient presented with symptoms of muscle weakness, pain, and impaired physical coordination.  The patient was prescribed a mammogram and bone density exam for their annual screenings. The patient will have a one-month follow-up appointment to discuss the results and obtain a refill for their medication.

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Current Medications:

1. Xanax 1mg PO, every morning for management of anxiety.

Allergies: There is no documented evidence of any allergies to drugs, foods, or environmental factors.

PMHx:

Medical problem list: Muscle weakness and pain

Preventative care: The latest influenza vaccination for this season is documented in her vaccination record. Nevertheless, she received a tetanus vaccination two years prior.

Surgeries: denies having a surgical past.

Hospitalizations: denies any previous hospitalizations

Soc Hx: The patient is single and lives alone. She currently serves as the dean of a business school, a role she has occupied for seven years. The patient also smoked one pack of cigarettes a day at the moment and had a smoking history of 21 pack-years. The patient’s alcohol consumption consists of an average of 2-3 beers per day during weekdays and a 2-pack per day during weekends. There is no evidence of involvement in the use or possession of illicit substances.

Fam Hx: Her father passed away at the age of 62 due to a myocardial infarction despite having a previous medical history of RA. Despite being 80 years old, her mother continues to live despite being diagnosed with type 2 diabetes. Her brother, who is 57 years old, is currently in good health.

ROS:

*GENERAL: denies having a fever, chills, altered appetite, or gaining weight.

*HEENT: denies experiencing headaches or concussions. No experience with double vision or other vision problems. Denies having cataracts, floaters, intense crying, glaucoma, or pain in the eyes. Denies hearing loss, ear infections, or tinnitus. Denies ever having nasal bleeds or sinus problems. No stuffiness, discharge, nasal obstruction, or changes in smell perception. There is no oral or throat pain, sore throat, pyorrhea, ulcers, bleeding gums, dryness, uncomfortable tongue, or hoarseness.

*SKIN: denies any signs of skin color changes, rashes, sores, bruises, lumps, or pruritus.

*CARDIOVASCULAR: denies experiencing chest pain, edema, dyspnea, or palpitations.

*RESPIRATORY: denies ever experiencing wheezing, asthma, or bronchitis.

*GASTROINTESTINAL: denies having constipation, diarrhea, or bloating.

*GENITOURINARY: denies having dysuria, polydipsia, or polyuria.

*NEUROLOGICAL: denies feeling lightheaded or having trouble with balance or coordination.

*MUSCULOSKELETAL: reports weakness and soreness in the muscles.

*HEMATOLOGIC: denies browsability, bleeding problems, or anemia.

*LYMPHATICS: no sign of enlarged lymph nodes. Denies having ever had a splenectomy.

*PSYCHIATRIC: reports having a history of anxiety disorder, which she effectively treats with medicine. Denies having delusions or hallucinations.

*ENDOCRINOLOGIC: denies being sensitive to extremes of temperature or humidity. Not polydipsia, nor polyuria.

*ALLERGIES: No recognized sensitivity to drugs, foods, or surroundings.

Objective

Physical exam:

Vital Signs: BP 133/84 mm Hg; RR19; pulse 89; SpO2 98.9%; Temp 98.9°F; Wt.: 151lbs; Ht: 5’6”.

General: healthy with just a little apparent pain. Aware and focused on the person, the moment, and the place. Very helpful and friendly.

HEENT: head non-traumatic. Pupils that are equal in size, round in shape, responsive to light, and capable of accommodating. Intact extraocular movements. Typical for fundamentalists. The sclera is a standard anatomical feature. Ensure proper nasal and aural hygiene. intact tympanic membranes. The oral mucous membranes are pink and moist.

Neck: Supple with no cervical adenopathy. Thyroid that cannot be felt. There are no abnormal sounds detected in the carotid arteries. There is no jugular venous distension observed.

Chest: examination reveals absence of wheezing bilaterally. There are no squeaks.

Heart: The heart exhibits a consistent rhythm and rate. S1 and S2 are observed. S3 and S4 absent. No rubbing or galloping.

Abdomen: Soft, non-tender, and non-distended. There are no signs of stiffness, rebound tenderness, muscle guarding, or palpable masses. There is no organomegaly. Frequent and regular defecation

Genitalia: Age of menopause 46. Denies UTI or any other gynecological disorder

Extremities: bilateral upper extremity strength of 5/5 with complete range of motion. Pain with forward flexion in 5/5 lower extremities; reduced range of motion. Every extremity is warm, without soreness or crepitus, and the color is typical for the ethnicity. Negative drawer test results. There is a negative McMurray test.

Neurological: focused and awake. The patient is x4 awake, focused, and aware. Grossly intact cranial nerves 2–12. Deep tendon reflexes: 2+ in the Achilles tendon, patellar reflex, brachioradialis reflex, bilateral biceps reflex, and triceps reflex. Sensory: unharmed. The patient walks with stability. Failure of the Romberg test

Diagnostic tests needed and results: The patient was given an order for yearly examinations that included a bone density assessment and mammography.

Assessment.

Differential Diagnoses:

1. 1 Generalized Anxiety Disorder: The patient reports a history of taking Xanax for the management of her anxiety disorder(Kolbe et al., 2020).
2. 81 Muscle weakness (generalized): The patient reports generalized muscle weakness that is worse on the lower extremities (Schefold et al., 2020).
3. 1 Myalgia: The patient reports muscle pain that is worse on the lower extremities (Burke-Doe, 2019).

Plan.

Diagnostics: bone density assessment and mammography (Poly et al., 2019).

Pharmacological Intervention: Continue with 1mg Xanax orally once daily, and reevaluate the dose after four weeks(Kolbe et al., 2020).

Non-pharmacological intervention: Exercise and yoga are advised for enhancing physical health and restoring muscle strength (Schefold et al., 2020).

Patient Education: It is important to provide the patient with information regarding the potential side effects of Xanax and strategies for managing them (Schefold et al., 2020).

Follow-up: The patient is required to revisit the clinic after four weeks in order to review their laboratory results and make any necessary adjustments to their treatment plan (Poly et al., 2019).

Reflection statement–

The patient in the case study exhibits muscle weakness and joint pain, potentially resulting from the extended usage of Xanax. She has been utilizing the medication for an extended duration to manage her anxiety disorder. Using Xanax carries the potential for drug addiction or dependency (Poly et al., 2019). The elderly population is at risk of experiencing sedation and musculoskeletal weakness, which can increase the likelihood of falls (Schefold et al., 2020). These falls can have serious consequences for this demographic. Therefore, it is imperative to evaluate the patients’ fall risks and bone density.

References

Burke-Doe, A. (2019). Clinically Relevant Drug-Induced Myopathies. Topics in Geriatric Rehabilitation, 35(1), 72–78. https://doi.org/10.1097/tgr.0000000000000217

Kolbe, V., Rentsch, D., Boy, D., Schmidt, B., Kegler, R., & Büttner, A. (2020). The adulterated XANAX pill: a fatal intoxication with etizolam and caffeine. International Journal of Legal Medicine, 134(5), 1727–1731. https://doi.org/10.1007/s00414-020-02352-7

Poly, T. N., Islam, Md. M., Yang, H.-C., & Li, Y.-C. J. (2019). Association between Benzodiazepine Use and Risk of Hip Fracture in the Elderly People: A Meta-analysis of Observational Studies. Joint Bone Spine. https://doi.org/10.1016/j.jbspin.2019.11.003

Schefold, J. C., Wollersheim, T., Grunow, J. J., Luedi, M. M., Z’Graggen, W. J., & Weber‐Carstens, S. (2020). Muscular weakness and muscle wasting in the critically ill. Journal of Cachexia, Sarcopenia and Muscle, 11(6), 1399–1412. https://doi.org/10.1002/jcsm.12620

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• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently in a similar patient evaluation?
• Patient Information below. YOu can make up the additional information.

 

Category	Item	Value
Client Information	Site	Nursing home
	Age	22–64 years
	Gender	Female
Visit Information	Student Level of Function	Independent – Level 5
	Category of Care	Direct Patient Care
Practice Management	Type of visit/phys. exam	Chronic office – 99212
Diagnosis	1 Anxiety
Student Notes	The patient came in today for a one-month follow-up visit for a prescription refill. The patient received a refill of 1mg of Xanax once a day. The patient received an order for a mammogram and bone density exam for annual screenings. The patient will follow up in one month to review the results and for medication refill.