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Posted: April 27th, 2023
Delete all text in red - these are instructions and not part of the SOAP document.
Prompt: Patient has hip pain.
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Requirement:
APA format
Intext citation
References at least 4 high-level scholarly reference per post within the last 5 years in APA format.
EACH differential diagnostic gets 1 reference
Plagiarism free.
Turnitin receipt.
ID:
Client’s Initials*:_______Age_____ Race__________Gender____________Date of Birth___________
Insurance _______________ Marital Status_____________
*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.
Subjective:
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CC: Patient’s own words, a few words, a sentence or less. Example: “cough and fever”
HPI:
In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.
Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.
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Past Medical History:
● Medical problem list
● Preventative care: (if applicable to the case - Paps, mammography, colonoscopy, dates of last visits, etc.)
● Surgeries:
● Hospitalizations:
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● LMP, pregnancy status, menopause, etc. for women
Allergies:
Food, drug, environmental
Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use
Family History:
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Social History:
-Sexual history and contraception/protection (as applies to the case)
-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)
Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here - what is pertinent and necessary for safe and holistic care)
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ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed - review and document the pertinent systems. Do not include diagnoses - those belong in PMH. The below categories are per CMS guidelines.
Constitutional:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & breast:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Objective
Vital Signs: HR BP Temp RR SpO2 Pain
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Height Weight BMI (be sure to include percentiles for peds)
Labs, radiology or other pertinent studies: be sure to include the date of labs - might be POC tests from today
Physical Exam (write out by system):
Start with a general survey:
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Assessment
(you will often have more than one diagnosis/problem, but do the differential on the main problem)
Differentials (with a brief rationale for each include ICD-10):
1. Hip Osteoarthritis
2. Sacroiliac joint dysfunction
3. Rheumatoid arthritis of the hip
Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)
Plan (4 pronged-plan for each problem on the problem list)
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Diagnostics:
Treatment:
Education
Follow Up:
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List plan under each Diagnosis.
Example
1: Hypertension (I10)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed
2: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education
3: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when sick
E. Return to clinic in 3-4 months to reassess
ID:
Client’s Initials: XXX Age: 52 Race: Hispanic Gender: Female Date of Birth: Jan 1, 1971
Insurance: XYZ Marital Status: Married
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Subjective:
CC: "I have been experiencing hip pain for a few months now."
HPI:
Ms. XXX, a 52-year-old Hispanic female presents to the clinic alone with a complaint of hip pain. The pain started a few months ago and is located in her right hip joint. The pain is constant and is worsened with movement, especially when she walks or stands for a prolonged period. She rates her pain as a 6 out of 10 in severity. She has been taking over-the-counter pain medications, which provide temporary relief. She denies any injury, trauma, or falls to the hip. There is no radiation of pain, no numbness, tingling, or weakness in her lower extremities. She denies any fever, chills, night sweats, weight loss, or loss of appetite.
Past Medical History:
● Medical problem list: Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus
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● Preventative care: Mammography (last done in 2021)
● Surgeries: Cholecystectomy in 2010
● Hospitalizations: None
● LMP, pregnancy status, menopause, etc. for women: Menopause at age 48, last menstrual period was 2 years ago.
Allergies:
NKDA
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Medications:
Lisinopril 10 mg once daily for hypertension
Atorvastatin 20 mg once daily for hyperlipidemia
Metformin 500 mg twice daily for type 2 diabetes mellitus
Family History:
Mother has hypertension and hyperlipidemia. Father died of lung cancer at age 68. No siblings.
Social History:
Non-smoker, denies any alcohol or illicit drug use.
Works as a receptionist at a local clinic, sedentary job.
Married for 25 years, has 2 grown-up children.
No sexual activity for the past year.
No other relevant social history.
ROS:
Constitutional: Denies any fever, chills, night sweats, fatigue, or weight loss.
Eyes: Denies any visual changes or blurring.
Ears/Nose/Mouth/Throat: No hearing loss, tinnitus, nasal congestion, or sore throat.
Cardiovascular: Denies any chest pain, palpitations, or edema.
Pulmonary: No shortness of breath, cough, or wheezing.
Gastrointestinal: Denies any abdominal pain, nausea, vomiting, or diarrhea.
Genitourinary: No dysuria, hematuria, or urinary incontinence.
Musculoskeletal: Constant right hip pain with movement. No history of joint pain, stiffness, or swelling in other joints.
Integumentary & breast: No skin changes or breast lumps.
Neurological: No history of numbness, tingling, or weakness in any body parts.
Psychiatric: No anxiety, depression, or sleep disturbances.
Endocrine: Type 2 Diabetes Mellitus, well-controlled with metformin.
Hematologic/Lymphatic: No history of easy bruising or bleeding.
Allergic/Immunologic: No known drug allergies.
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Objective:
Vital Signs: BP 128/78 mmHg, HR 80 bpm, RR 18 breaths/min, Temperature 98.6 °F, SpO2 99%, Pain 6/10
Assessment:
Ms. XXX is a 52-year-old Hispanic female with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus who presents with constant right hip pain for the past few months. The pain is worsened with movement, especially when she walks or stands for a prolonged period. There is no history of injury, trauma, or falls to the hip, and no radiation of pain, no numbness, tingling, or weakness in her lower extremities. Her vital signs are within normal limits, except for her BMI, which is in the obese range.
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Based on the above history and examination, the most likely diagnosis is osteoarthritis of the right hip joint. The patient's sedentary job and BMI may contribute to the development of osteoarthritis. The differential diagnosis includes trochanteric bursitis, hip labral tear, and femoral neck stress fracture.
Plan:
Ordering diagnostic tests:
a. X-ray of the right hip joint to evaluate for osteoarthritis or any other bony abnormalities.
b. CBC, ESR, and CRP to rule out any infection or inflammatory condition.
c. Vitamin D and calcium levels to rule out any nutritional deficiencies.
Medications:
a. Acetaminophen or NSAIDs for pain relief as needed.
b. Referral to a rheumatologist for further evaluation and management if the X-ray suggests osteoarthritis.
Lifestyle modifications:
a. Encouragement for weight loss and regular exercise to decrease the risk of developing osteoarthritis or to alleviate the symptoms of the condition.
b. Physical therapy referral to strengthen the hip muscles and improve range of motion.
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Follow-up:
a. Follow-up appointment in 2 weeks to review X-ray results and assess the efficacy of pain management.
b. Referral to pain management or orthopedic specialist if symptoms persist or worsen despite conservative management.
Height: 5'4", Weight: 180 lbs, BMI: 30.9
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