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Original Question
make this into a soap note : HPI: 74 year old female coming in with complaints of bilateral hand pain. She says she had bilateral shoulder pain 6 days ago where she was unable to move. She did see another provider she reports. She says her hands have been swollen and tender for 2 days now. Reports she is unable to fully open and close her hands and is reporting pain is worse at night. ROS:Const: Denies chills and fever.ENMT: Denies mouth or throat symptoms.CV: Denies chest pain.Resp: Denies SOB.GI: Denies diarrhea, nausea and vomiting.GU: Urinary: denies dysuria and incontinence.Musculo: Reports joint pain.Skin: Denies rash.Neuro: Denies numbness/tingling.Psych: Denies depression. Current Meds: Zoledronic Acid 5 mg/100ml, Escitalopram Oxalate 20 mg, Potassium Chloride Crys ER 20 meq, Zofran 4 mg, Levothyroxine Sodium 100 mcg, Rosuvastatin Calcium 20 mg, Pantoprazole Sodium 40 mg, Diclofenac Sodium 1 %, Albuterol Sulfate (2.5 mg/3ml) 0.083%, Furosemide 40 mg, Ibu 800 mg, Vitamin D-1000 Maximum Strength 1000 Unit, Nitrostat 0.4 mg, Ventolin HFA 108 (90 base) mcg/act, Trelegy Ellipta 200-62.5-25 mcg/ActAllergies: Morphine, Spiriva, Ceftriaxone – anaphylaxis Objective BP Right Sitting: 118/72 Wt: 186lb Wt Prior: 188lb as of 04/14/25 Wt Dif: -2lb Ht: 65.25″ 5’5.25″ BMI: 30.7 Pulse: 94 O2SatR: 90 T: 98.0 Exam:Const: Appears healthy. Appears to be stable in weight. No signs of acute distress present.Head/Face: Normal on inspection.Eyes: Conjunctivae: Clear.
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