Musculoskeletal Pain SOAP Note Transcription Sample Report
REASON FOR CONSULT: This is a (XX)-year-old female seen for musculoskeletal pain and positive rheumatoid factor.
SUBJECTIVE: The patient developed myalgia at the upper legs and also bilateral knee pain recently. According to her, there was no swelling of the knees, but there was slight morning stiffness lasting a few minutes. She denies symptoms at the hands, elbows, shoulders, hips, ankles, feet. She denies neck pain.
She has slight dry mouth. She denies chest pain, cough, dyspnea, diarrhea, dysuria, leg edema, Raynaud’s phenomenon, muscle weakness, paresthesia, fever. She has occasional stomach pain lasting seconds.
Her past medical history is significant for acne treated with Accutane. She denies history of hepatitis C infection, tuberculosis, syphilis or liver disease.
Family history is unremarkable for rheumatoid arthritis or lupus.
She takes Advil occasionally for musculoskeletal pain. She says she takes two pills if needed. She is also taking Accutane.
OBJECTIVE: Normal appearance, in no acute distress. HEENT: No dry eyes or dry mouth. Heart: Regular rate and rhythm, no murmur. Lungs: Clear with no wheeze or rub. Abdomen: No tenderness. Extremities: No finger cyanosis or leg edema. Skin: No rashes or cutaneous nodules. Hands: No tenderness or swelling of the IPs, MCPs, wrists. Elbows: No tenderness or swelling with normal flexion and extension. Shoulders: No tenderness or reduced range of motion. Hips: No trochanteric tenderness with normal range of motion. Knees: Mobile patellae but no joint line tenderness or swelling, normal flexion and extension. Ankle and Foot: Unremarkable. Neck: No cervical spine tenderness. Lower Back: No lumbosacral tenderness. Muscles: No quadriceps tenderness, but the hamstrings were tight. Neurologic: No weakness or sensory changes.
LABORATORY DATA: Recent rheumatoid factor was positive at 23.6 with normal being less than 12. ESR was normal at 14 with normal being 0-25. Her CBC showed a slight anemia and her ferritin was low normal.
ASSESSMENT AND PLAN: The patient at present has musculoskeletal pain, particularly upper legs, and positive rheumatoid factor. The pain is mainly myalgia and not arthralgia. She did have slight knee pain, but I think she has patellofemoral syndrome rather than synovitis. Her other joint exam is unremarkable. Rheumatoid factor can be related to rheumatoid arthritis, but it can also be related to infectious diseases such as hepatitis C infection, tuberculosis and syphilis.
It was suggested that she check additional tests, including CCP antibody, hepatitis C serology, syphilis serology and PPD. If the CCP antibody is positive, she definitely has rheumatoid arthritis. She will need to be seen here again for further evaluation and treatment.
If the infectious disease tests are positive, she will be treated accordingly by Dr. John Doe. If both are negative, she needs to monitor development of new joint symptoms, particularly in the hands, particularly in the morning. If that occurs, she should also return for further evaluation. For the myalgia, she might have patellofemoral syndrome, and as such, she will modify her activities. She knows to apply heat for treatment.
