Problem-Focused SOAP Note Format

Demographic Data: A.R, 49 y/o, female. She resides in a SNF.

Subjective

Chief Complaint (CC): A.R, came to the facility for medical follow-up. Her health status had been discussed with the nursing staff before the in-person assessment.

History of Present Illness (HPI): The 40 y/o female came to SNF for medical follow-up. Her appetite is normal, she is capable of feeding herself, and the diet is regular solid. She denies fever, chills, dyspnea, and night sweats and sleeps without a sleep aid. 

Past Med. Hx (PMH): No history of medical or surgical problems, hospitalizations, and medications. The patient is allergic to aspirin.

Family Hx: There is no known history of the patient’s close relatives and illnesses.

Social Hx: The patient has no known history of alcohol or tobacco use.

Review of Systems (ROS)

General: The patient denies fever, fatigue, recent weight gain or loss, and night sweats.

HEENT: The patient denies visual changes, sore throat, difficulties in talking regular solid food, hearing changes, headache, or dizziness.

Pulmonary: The patient denies dyspnea and chest pain.

Cardiovascular (C/V): The patient denies shortness of breath, chest pain or pressure, irregular heartbeat, and wounds in the feet.

Gastrointestinal: The patient denies changes in bowel habits.

Genito-Urinary: The patient denies any signs of incontinent urine discharge.

Ob/Gyn/Breast: The patient denies sweats.

Neurological: The patient denies dizziness, weakness, headache, and balance problems.

Endocrine: The patient denies weight loss or gain, fatigue, or polyuria.

Musculoskeletal: The patient denies lower back pain but suggests that she has pain in the lower extremities.

Mental Health. No memory loss and the patient denies memory issues or depression.

Objective

General: no acute distress, alert

Psychiatry: appropriate affect, appropriate behavior

Neurology/Musculoskeletal: CN grossly intact, reduced range of motion noted.

Cardiovascular: Deferred

Pulmonary: no increased work of breathing, no accessory muscle use

Abdomen: non-tender, non-distended

Genitourinary: continent of urine and stool

Lower extremities: Contracture of bilateral lower extremity

Dermatology: no rash or lesions

Assessment

Differential Diagnosis

1. Major Depressive Disorder, Single Episode, Unspecified (F32.9)

Major depressive disorder is characterized by recurrent feelings of despair, sadness, and loss of energy to undertake normal daily activities of living. Other symptoms associated with major depressive disorder include feelings of hopelessness and triviality, changes in sleeping habits and eating patterns, loss of pleasure in activities that were once enjoyable, and thoughts of suicide or death (Bains & Abdijadid, 2021). The patient has only had a single episode of loss of energy and feelings of despair. She does not present with any of the other symptoms, meaning that a diagnosis of major depressive disorder is unlikely.

• Generalized Anxiety Disorder (F41.1)

Generalized anxiety disorder is characterized by exaggerated and excessive worry and anxiety about everyday events, even those that warrant no such emotions. The disorder predisposes people to disaster expectations, and in some cases, it is difficult to stop worrying about normal things, such as work, school, and family (DeMartini et al., 2019). Other diagnostic criteria include trouble concentrating, sleeping difficulties, muscle ache, tension, or soreness, fatigue, unrealistic perception of problems, restlessness, and increased irritability (DeMartini et al., 2019). The patient has muscle tension and relatively mild anxiety. However, she denies trouble sleeping, concentrating, and fatigue. Therefore, the diagnosis is unlikely.

Final Diagnosis

1. Contracture of Right and Left Knee

Due to the patient’s presenting symptoms and physical examination, multiple sclerosis is diagnosed. Pertinent positives include joint pain, impaired joint mobility, decreased range of motion, and contracture of the bilateral lower extremity. Contractures result from a permanent shortening of muscle fibers and changes in regular muscle structure (Harvey et al., 2017). They also result from a reduction in satellite cells that are responsible for the repair and regeneration of muscles. Inadequate amounts of satellite cells give room for other cells, including fibroblasts, to regenerate inside muscle tissue, resulting in stiff muscle fibers (Harvey et al., 2017). Contracture of the bilateral lower extremities, reduced range of motion, and joint pain are the primary reasons for the contracture of right and left knee diagnosis.

Plan

Physical therapy is recommended to help decrease the severity of muscle contractures. The therapy will enable the reduction of muscle tightness through soft tissue mobilization and stretching. Pharmacological interventions include taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.

Reference

Bains, N., & Abdijadid, S. (2021). Major depressive disorder. In StatPearls [Internet]. StatPearls Publishing.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Harvey, L. A., Katalinic, O. M., Herbert, R. D., Moseley, A. M., Lannin, N. A., & Schurr, K.(2017). Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews, (1). https://doi.org/10.1002/14651858.CD007455.pub3