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Assessing Musculoskeletal Pain

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Subject
Nursing
School
Walden University
Type
Homework
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Assessing musculoskeletal pain
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Institutional Affiliation
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Episodic/ focused SOAP note for a patient with pain in both ankles.
Patient information: 46 years old female. Plays soccer.
S.
CC (chief complaint) pain in both ankles but with specific concern to the right ankle. The
patient claims to have been playing soccer over the weekend and heard a "pop" sound in her
ankle.
HPI: The patient is a 46-year-old woman who presents to the clinic with pain in both of her,
with the pain in her right ankle being of major concern. The patient claims that she was
playing soccer over the weekend and heard her ankle's "pop" sound. The patient also
describes that she feels pain while bearing weight. The patient also claims that it is
uncomfortable to take the weight, that the pain is more while carrying weight.
Current medication: the patient has taken painkillers, Tylenol 650 mg orally, to help with
the pain. There were no prescription medicines taken.
Allergies: there were no known allergies. The patient denies environmental, food or latex
allergies.
Past medical history: the patient denies having any medical procedures or hospitalization.
The patient has taken the tetanus vaccine as a preventive measure and has taken all the
possible vaccinations.
Soc hx: the patient does not take tobacco or use alcohol, and the patient has been in a
monogamous relationship for the past ten years. The patient says she takes healthy diets and
does not eat fast food.
Fam Hx: mother hx of HTN, father hx of CHF. The maternal a paternal grandparents are
deceased, and the patient is unsure of how they died.

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1 Assessing musculoskeletal pain Name Institutional Affiliation Course Instructor Date 2 Episodic/ focused SOAP note for a patient with pain in both ankles. Patient information: 46 years old female. Plays soccer. S. CC (chief complaint) pain in both ankles but with specific concern to the right ankle. The patient claims to have been playing soccer over the weekend and heard a "pop" sound in her ankle. HPI: The patient is a 46-year-old woman who presents to the clinic with pain in both of her, with the pain in her right ankle being of major concern. The patient claims that she was playing soccer over the weekend and heard her ankle's "pop" sound. The patient also describes that she feels pain while bearing weight. The patient also claims that it is uncomfortable to take the weight, that the pain is more while carrying weight. Current medication: the patient has taken painkillers, Tylenol 650 mg orally, to help with the pain. There were no prescription medicines taken. Allergies: there were no known allergies. The patient denies environmental, food or latex allergies. Past medical history: the patient denies having any medical procedures or hospitalization. The patient has taken the tetanus vaccine as a preventive measure and has taken all the possible vaccinations. Soc hx: the patient does not take tobacco or use alcohol, and the patient has been in a monogamous relationship for the past ten years. The patient says she takes healthy diets and does not eat fast food. Fam H ...
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