KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

ADULT, WOMEN, GERIATRICS

Student Allison Rogers Course NURS 5018

SOAP Note #4 (Chronic Illness-Focused)

Pt. Initials: S.H. Age: 54 DOB: 10-17-61 LMP: 2008 (postmenopausal)
(S) CC: New onset right hip pain, monthly checkup for chronic back pain and left leg
neuropathy.
HPI:

Character: Pressure

Onset: Dull ache since back surgery in 2001, constant pressure began approximately three
weeks ago.
Location: Right hip

Duration: Constant pressure for approximately three weeks

Severity: Rates 7/10 on pain scale

Pattern: Heat makes discomfort some better, walking and standing for periods of time makes
discomfort worse.
Associated: Denies decrease in range of motion, muscle pain, swelling, hot, or reddened areas.
States minimally interferes with daily activities, just not able to do all that I want to do without
having to rest my hip.
Medical Hx: Neuropathy, arthritis, depression, acid reflux

Surgical Hx: Lumbar fusion, right trigger thumb release, left knee surgery (x2)

Social Hx: Never married with no children, lives with sister after mother passed away five
months ago, reports good support system from siblings. Smokes cigarettes, 0.5 pack per day for
approximately 40 years. Denies current or past alcohol, or illicit drug use. Not employed, works
in yard, weedeats, and gardens at home.
Family Hx: Mother (deceased age 79- AAA) hypertension, abdominal aortic aneurysm; Dad
(deceased age 70s- brain aneurysm) hypertension, abdominal aortic aneurysm, brain aneurysm;
brother- hypertension; sister- hypertension

Allergies: Flagyl (hives), Augmentin (hives)

Meds: Lyrica 100mg BID, Zanaflex 4mg TID, Ultram 50mg TID, Norco 10/325mg every 6
hours PRN, Roserum 8mg at bedtime, Elavil 25mg at bedtime, Celexa 20mg at bedtime,
Protonix 40mg at bedtime, Vitamin D 1000 IU daily, magnesium oxide 400mg daily, Colace
100mg daily PRN, Miralax 17gram daily PRN
ROS: General: Reports not very well rested, states has to get up few times per night due to
back pain. Denies fever, chills, recent unexplained weight gain or loss.
HEENT: (Not pertinent to this focused exam)

Skin: Denies rashes, puritis, edema, ulcerations or breaks in skin, hot areas of skin, excessive
ecchymosis, or erythema.

Respiratory: Denies shortness of breath with or without exertion, orthopnea, hemoptysis,

cough, congestion, wheezing, or crackles.
Cardio: Denies chest, arm, or neck pain with or without exertion. Denies palpitations, edema,
or syncope.
GI: Reports acid reflux seems well controlled with Protonix. Denies heartburn, reflux,
dysphagia, nausea, vomiting, loss of appetite, abdominal pain, bloating, or diarrhea. Reports
occasional constipation, states resolves with over the counter Miralax or Colace stool softener.
GU: Denies urinary hesitancy or incontinence.

Diet: No changes in typical diet. Reports drinking mainly water. Reports occasionally eating
late at night immediately before going to bed.
Endocrine: (Not pertinent to this focused exam)

MS: Reports joint pain in right hip and tailbone area. Denies weakness, swelling, decreased
range of motion, muscle pain or spasms.
Neuro: Complaints of numbness and tingling in left leg and foot at times, states it comes and
goes at rest and while walking/ standing. Denies numbness or tingling feelings in right lower
extremity or any other parts of body, denies burning sensations or tremors.
Psych: Reports depression symptoms seem well controlled with Elavil and Celexa. Denies
feelings of anxiety, panic, suicidal thoughts or tendencies.
(O)

Vital signs: T: 98.9F P: 100 R: 20 BP: 135/86 HT: 56 WT: 122 BMI: 19.7 Pain: 7/10

Constitutional - Pleasant, groomed Caucasian woman, dressed appropriately for age and
weather. Cooperative and answers questions appropriately. No grimacing, guarding, or acute
distress noted.
HEENT: (Not pertinent to this focused exam)
Skin: Warm, dry, intact. No abrasions, lacerations, erythema, or ecchymosis.

Respiratory: Clear to auscultation in all lobes, no wheezing, crackles noted.

Cardio: Normal rate and rhythm, no murmurs, rubs, gallops noted, S1 and S2 present.

GI: Normoactive bowel sounds present in all four quadrants, soft non-tender, no organomegally,
and no abdominal distension noted.
GU: Not pertinent to this focused examination

Endocrine: (Not pertinent to this focused exam)

MS: Painful right sacroiliac area upon palpation, no pain reported with palpation of right hip
joint. Hardware palpated to right lumbar region. No swelling or redness noted to joint areas
bilaterally. Full range of motion noted to neck, bilateral shoulders, arms, fingers, hips, knees,
ankles, and toes. Muscle strength equal and strong bilaterally legs and feet.
Neuro: Alert and oriented to person, place, time, and event. Able to feel monofilament on all
aspects of feet and toes bilaterally. No tremors.
Psych: Appropriately interacts and answers questions appropriately. Appropriate affect, no flat
affect, jitteriness, or fidgeting noted.

Other: None

(A)
Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes )(list as many
diagnoses as indicated)

M25.551 Right hip pain

Differentials:

1- M19.93 Secondary osteoarthritis, unspecified site

2- M25.751 Osteophyte, right hip
3- M46.1 Sacroilitis, not elsewhere classified
4- M46.98 Unspecified inflammatory spondylopathy, sacral and sacrococcygeal region
(P) (Include costs of tests, medications, etc. can find resources for this at
http://www.nlm.nih.gov/services/drug_procedure_costs.html; www.epocrates.com,
http://www.goodrx.com)

1- X-ray right hip (FREE at Clintwood Health Wagon Clinic). According to cost helper (2016),
the usual price of a patient without insurance to obtain an x-ray of the hip is around $463.

2- Prescription for Norco 10/325mg every six hours as needed (120 tablets). According to Good
Rx (2016a), for the Wise, Virginia area a prescription for Norco 10/325mg 120 tablets cost
$27.48 with free discount at Wal-Mart, $29.86 with free coupon at CVS, and $70.59 with free
coupon at Rite-Aid.

3- Intramuscular injection of Toradol 60mg once at clinic (FREE at clinic). According to Good
Rx (2016b), for the Wise, Virginia area a 60mg vial of Toradol cost $3.57 with free discount at
Wal-Mart, $8.88 with free coupon at Rite-Aid, and $9.68 with free coupon at CVS.

Pt.Education: Encouraged to increase fiber and water intake when taking frequent doses of
narcotic pain medications and continue to use Colace over the counter as needed to prevent
narcotic induced constipation. Use heat or ice as needed to ease discomfort, may use NSAIDS,
such as ibuprofen up to three times daily, using caution of increased doses or extended use due to
history of acid reflux.
Preventive care: Encouraged to wear supportive shoes when up to prevent damage to feet
during times of neuropathy. Stressed the importance of smoking cessation to promote proper
oxygenation to bones. Encouraged to limit activities, as much as possible, that cause increased
discomfort.
Follow-up instructions: Will notify with results of right hip x-ray and adjust treatment plan as
needed. Keep scheduled follow up in one month.
Other: None

Discuss how you addressed at least 3 NONPF competencies during this visit. (See
NONPF competency list available at
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecom
petenciesfinal2012.pdf )

1. Leadership Competencies
According to Thomas et al. (2012), this competency can be fulfilled through problem solving,
critical, and reflective thinking. I feel that this competency was fulfilled through attempting to
get to the cause of the new onset right hip pain by obtaining a right hip x-ray and evaluating the
situation further after results are obtained.
2. Practice Inquiry Competencies
Thomas et al. (2012), states this competency is fulfilled through the application of clinical
investigative skills to improve health outcomes. I feel this competency was fulfilled through
explaining the urgency of smoking cessation in order to deliver adequate amounts of oxygen
needed for bones, as well as other body structures and organs, to thrive.
3. Health Delivery System Competencies
According to Thomas et al. (2012), this competency is fulfilled through being conscious and
providing cost-effective care. The patient population cared for at this clinic is indigent, without
insurance, by providing the Toradol injection in the clinic and x-ray at the Clintwood clinic near
the patients home, all free of charge, my preceptor was trying to be as cost effective for the
patient as possible, without ordering multiple costly tests.

References
Cost helper [Internet]. (2016). X-ray cost: How much does an x-ray cost? Retrieved from

costhelper.com website: http://health.costhelper.com/x-rays.html

Good Rx [Internet]. (2016a) Norco. Retrieved from goodrx.com website:

http://www.goodrx.com/norco?=&form=tablet&dosage=10mg-

325mg&quantity=120&days_supply=&label_override=hydrocodone / acetaminophen

Good Rx [Internet]. (2016b). Toradol. Retrieved from goodrx.com website:

http://www.goodrx.com/toradol?=&form=vial&dosage=2ml-of-60mg-

2ml&quantity=1&days_supply=&label_override=ketorolac

Thomas, A. C., Crabtree, M. K., Delaney, K., Dumas, M. A., Kleinpell, R., Marfell, J. Wolf,

A. (2012). Nurse practitioner core competencies. The National Organization of Nurse

Practitioner Faculites. Retrieved from:

http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcor

ecompetenciesfinal2012.pdf