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SOAP NOTE EXERCISE NEUROLOGICAL AND MUSCULOSKELETAL SYSTEMS Charles Ottosen 11/9/2012 NG 304 EWC Instructor: Dr.

. Massey (S)ubjective: Pt. Lucy Bento (23 y.o., female, Caucasian) from Gainesville, GA presented with a complaint of: my left shoulder hurts. Character: Feels a grating and sometimes pops. Aches otherwise. Onset: 3 months ago. After a workout. Location: Left shoulder. Points at area of AC joint. Radiates into biceps and triceps. Duration: Pain is worse in morning until she gets moving. Recurs after lifting weights. Severity: Describes pain as ranging from 2-5 on a scale of 10. Currently a 3. Pattern: Working out makes it worse, but doesnt want to give up workouts. Naproxen and Ice improves symptoms. Associated factors: Feels that her workouts are suffering and feels like she is getting fat. L.B. states that she has had previous aches and pains r/t working out, but none have persisted this long. Pt. states that she has had no chronic or congenital diseases. She considers herself very healthy and would like to get back to her regular level of work-out intensity. No surgeries, accidents, or allergies reported. Denies any back pain or other musculoskeletal pain. Up to date with immunizations. No numbness or tingling reported. Pt. denies seizures, headaches, or dizziness. No change in ability to smell, hear, see, taste, or feel. Pt. reports no memory loss or loss of muscle control. Ms. Bento is a Customer Service Representative who works in an office environment. She is a nonsmoker, non-drinker, and exhibits health seeking behaviors. She has a regular exercise routine of Cross-Fit style workouts every day. She describes this as circuit style exercise that includes Olympic lifts. She is married with no children. Her diet is balanced and clean where she showed me her diet journal of mainly fruits/vegetables/lean proteins. L.B.s father has a history of osteoarthritis. Her mother is healthy, but obese with high BP and blood lipids. No siblings. Grandparents, maternal and paternal, died of heart disease. No CVA, dementia, epilepsy, or CA in any family members.

(O)bjective: Pt. appears well groomed and toned with good posture. Talkative and happy, able to follow conversation and follow directions. A&O x 3. Her complexion is fair and shows no lesions. Well hydrated as evidenced by pinch test. BP: 118/60, HR: 58/min, R: 12/min even and regular. Even gait with proper, opposite arm swing. Muscular tone even bilaterally with smooth movement. Crepitus noted at TMJ; however, full range of motion in jaw. Spine is straight with no tenderness upon palpation. No redness, swelling or masses noted bilaterally in arms and shoulders. ROM limited at L shoulder. Pain elicited when attempting to raise arm above head (>90 degrees): abduction and forward flexion. Elbows: No pain or nodules noted: 160 degrees flexion, 180 degrees extension, 90 degrees supination.

No pain, nodules, crepitus, or limited ROM in wrists, hands, or fingers. Hips, knees, ankles, and feet are strong and are all equally strong with no lesions, redness, swelling, or limited ROM. Cranial Nerve Assessment: I: properly ID vanilla scent in both nostrils II: reads Snellen chart w/ 20/20 vision and reads at 14 inches w/o difficulty III/IV/VI: No ptosis, nystagmus, or strabismus. Able to follow pen through all cardinal fields. PERRLA. V: able to kept jaw clenched against resistance VII: symmetrically smiles, puffs cheeks, wrinkles forehead, closes eyes against resistance. VIII: able to hear fingers rubbed together in each ear IX/X: uvula and soft palate rise bilaterally. Able to swallow sip of water w/o difficulty. XI: Able to shrug shoulders against resistance. XII: Able to move tongue all directions against resistance. Able to touch finger to thumb, finger to nose, stand on toes, stand on heals, hop on one foot. Reports light touch/hot and cold at all extremities and proper location. Tactile discrimination intact: properly IDs object, area, and number written in hand while not looking. Deep tendon reflex at patellar, biceps, triceps, Achilles, 2+. (A)nalysis: Impaired Physical Mobility r/t impaired joint movement AEB inability to raise arm above 90 degrees (abduction and forward flexion) without acute pain and pt. reports of popping and aching at L shoulder joint. (P)lan: Consult with PT for evaluation and development of mobility plan. Explain/Educate pt. to carry out PT plan verbally and in writing. Assess level of motivation. Assist pt. in pain management with proper positioning and ice packs. Consult with HCP for possible pain meds and/or surgical intervention.