2. Mary is a 70-year-old widow with a history of osteoarthritis.She has been self-medicating with over-the-counter acetaminophen,either extra strength (500 mg/tablet) or arthritis strength(650mg/tablet) for over a year now. In addition to osteoarthritis,she also has osteoporosis and gastroesophageal reflux. She presentswith the complaint of backache and right knee pain, aggravated byclimbing stairs. She describes her knee pain as 8 on a scale of 1to 10: “I can stand the back pain, but the knee is awful.” Shelives alone but has two supportive daughters nearby. They take hershopping and help with housework. On good days, she goes to thesenior center for lunch and socialization. She was doing exercisesat the Senior Center but stopped due to her knee pain. She does notsmoke or drink alcohol, except at birthday parties andcelebrations. She denies any medication, food, or environmentalallergies. In addition to the acetaminophen, medications includecalcium with vitamin D, Protonix (pantoprazole), and an annualintravenous infusion of Reclast (zoledronic acid). She also hasbeen taking a dietary supplement of glucosamine/chondroitin for 3months. She recently had a complete physical examination withelectrocardiogram and laboratory tests and was told that everythingwas “normal.”
-This is SOAP note.
- differential diagnosis (Pertinent positive, negative)
- Subjective
- objectives
- the question to ask the patient
- working diagnosis(Pertinent positive, negative)
- pharmacological treatment
- Non pharmacological treatment
- education
- what healthcare promotion?
