Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic arthritic pain, evaluation of worsening pain, or medication management.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the severity and location of current pain.
Ask about aggravating and alleviating factors (activities, weather, medications).
Inquire about functional limitations due to pain (daily activities, work, hobbies).
Evaluate for any recent changes in pain pattern, stiffness, swelling, or morning stiffness duration.
Past Medical History:
Briefly summarize relevant past medical history, including:
Type of arthritis (osteoarthritis, rheumatoid arthritis, psoriatic arthritis, etc.)
Date of diagnosis
Previous treatments (medications, physical therapy, injections)
Comorbid conditions that might influence pain management (e.g., obesity, diabetes)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Musculoskeletal Exam:
Assess the affected joints for:
Joint tenderness
Joint swelling
Range of motion (active and passive)
Crepitus (grinding sensation)
Muscle weakness or atrophy (if present)
Assessment (A):
Pain Characterization:
Describe the type of pain (aching, sharp, burning) and its location.
Functional Impact:
Assess the impact of pain on daily activities, work, and overall well-being.
Arthritis Activity (if applicable to specific type of arthritis):
For inflammatory arthritis (e.g., rheumatoid arthritis):
Assess for morning stiffness duration, number of swollen and tender joints.
Differential Diagnosis (if atypical presentation):
Consider other causes of joint pain besides arthritis (e.g., bursitis, tendinitis, gout).
Plan (P):
Treatment Plan:
Develop a treatment plan to address pain, improve function, and slow disease progression (if applicable).
Consider options like:
Medications: Analgesics, NSAIDs, disease-modifying antirheumatic drugs (DMARDs) for inflammatory arthritis.
Physical therapy: Improve joint mobility, strengthen muscles, and manage pain.
Assistive devices (canes, braces): Support joints and improve function.
Non-pharmacologic pain management: Heat/cold therapy, weight management, relaxation techniques.
Referral (if indicated):
Consider referral to a rheumatologist (for inflammatory arthritis), physical therapist, or pain specialist.
Laboratory Tests (if indicated):
Order inflammatory markers (CRP, ESR) for suspected inflammatory arthritis.
Consider X-rays or imaging studies (MRI, ultrasound) to evaluate joint damage or rule out other diagnoses.
Follow-up:
Schedule follow-up visits to monitor pain response, medication effectiveness, and functional status.
Define the frequency of follow-up based on disease severity and treatment plan.
Patient Education:
Educate the patient about their specific type of arthritis, treatment options, importance of medication adherence, and self-management strategies (e.g., joint protection techniques, exercises).
Discuss potential side effects of medications and the importance of reporting any concerns.
Provide resources for support groups or educational materials on arthritis management.