SOAP musculoskeletal, pain assessment PDF

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SOAP assignment...

Description

N.M.

Algonquin Hospital

38; Nov-05, 1978 F

Progress Notes DATE & TIME

Musculoskeletal & Pain Assessment

Nov-18, 2016 08:45 Hrs.

Subjective: - Musculoskeletal: reports no joint pain, problems, stiffness, swelling, redness or heat; No muscle pain, cramping or weakness; No bone pain, deformities or trauma; No back pain or limits to ADLs; Occupation involves no musculoskeletal risk factors and no recent weight gain; minimal cardio exercise “about once a week”; no family history of arthritis, hip dysplasia, scoliosis, osteoporosis or cancer; history of depression and treatment with anti-depressants (not sure of brand); no use of anti-inflammatorys, muscle relaxants or pain relievers; use of aspirin “once a month” for headaches. - Pain: “crunchy or gratey” pain in both knees; pain alleviated w/ rest; pt has tried Advil to alleviate pain w/ no success; no radiation; “1-2” on pain scale and pt believes that walking causes it (due to friction rub); began 5 years ago and is relatively constant with movement; pt reduces activity to prevent pain. Objective: - Musculoskeletal: smooth, coordinated gait with ability to bear weight; joints and muscles symmetrical; no swelling, masses, deformity; normal spinal curvature; no tenderness to palpation of joints; no heat, swelling, or masses. Full ROM; movement smooth, no crepitation, no tenderness. Muscle strength: able to maintain flexion against resistance (5) with no tenderness. - Pain: pt calm and attentive; Even, relaxed breathing; no visible deformities or other signs of irregularity; no tenderness upon palpation. Assessment: - Musculoskeletal: Joints and muscles healthy and functional w/ no pain, stiffness or swelling. Minimal exercise and history of depressions w/ treatment by unknown brand of antidepressants - Pain: Chronic “crunchy” knee pain, believed by pt to be caused by walking/friction rubs. Pain is alleviated w/ rest and does not radiate. Pt reduces daily activity level to accommodate pain. I. Impaired comfort related to chronic pain (knee pain) II. Risk for overweight related to decreased activity patterns secondary to chronic pain III. Activity intolerance related to inactivity secondary to sedentary lifestyle Plan: No observable abnormalities and no tenderness on palpation; x-ray to determine cause of knee pain (potentially crepitus caused by arthritis). I. Reduce unnecessary daily activity and gently stretch knee if stiffness occurs II. Increase daily activity to reduce risk and ensure healthy diet is maintained. III. Try NSAIDs to reduce pain and prevent sedentary lifestyle. If pain is caused by arthritis, try analgesics or corticosteroids to reduce pain.

Nov-18, 2016 10:00 Hrs.

Nov-23, 2016 21:30 Hrs.

Nov-23, 2016 22:00 Hrs....