SOAP Note: Fibromyalgia
Patient’s Details
Initials: M.L. Age: 30 years Race: White Gender: Female
SUBJECTIVE:
Chief Complaint (CC): “I have been experiencing dull and constant pain all over my body. The pain occurs with extreme fatigue and stiffness in the joints especially in the morning. These symptoms have significantly affected my ability to function. I am psychologically troubled by these symptoms and I just need your help.”
History of Present Illness (HPI): M.L., a 30-year-old white female, has reported to the clinic complaining of dull and constant pain all over her body. M.L. reports that the pain occurs with extreme fatigue and stiffness in the joints especially in the morning. These symptoms have significantly affected her general ability to function. She is psychologically troubled by these symptoms and just needs help from a healthcare professional.
These symptoms have persisted for the past three months. M.L. does not associate her symptoms to a recent traumatic event. As reported by M.L., several other symptoms occur together with the ones already described and they include; memory difficulties, affected abilities to concentrate and think, frequent pain around the head and jaws, abdominal pain, boating, sleep disturbance, and a burning or pricking sensation in the hands and feet.
One thing that worries M.L. the most is that the pain and fatigue symptoms do not subside even with common painkillers and enough sleep. M.L. indicates that nothing relieves the pain but it is always constant. She denies having any other medical conditions. She reports using 2 tablets of Tylenol every six hours daily. The pain goes away only for a short period of time after using the medication but returns with high severity. She describes the pain level as 9/10 on the pain scale.
III. Past medical history (PHx)
Denies known childhood illnesses
As per her medical records, M.L. was immunized according to the schedule provided by the Centers for Disease Control. She received hepatitis B vaccine; 1st and 2nd doses, polio vaccine, rotavirus vaccine; 1st and 2nd doses, varicella vaccine, measles, mumps, rubella (MMR) vaccine, hepatitis A vaccine, pneumonia vaccine, and diphtheria, pertussis, and tetanus (DPT) vaccine. Her last influenza vaccine was on 05/01/2022.
M.L. reports malaria diagnosis at the age of 25 years. She was not hospitalized but was able to recover after treatment.
Denies a history of surgery.
No known drug or food allergies reported.
M.L. is currently using Tylenol to manage her pain. However, the drug does not improve her symptoms
She reports using massage of the joints to improve stiffness, especially in the morning.
M.L. is her parents’ only daughter. Both father and mother are alive. Her father is 61 years old and her mother is 57 years. Parents have not been diagnosed by any medical condition. Maternal and paternal grandparents are all alive. She is not aware whether they have any medical conditions.
M.L. is unemployed and reports that she spends better part of the day at home with the kids. Part of her daily activities include performing domestic chores and taking care of the children. She is married and they have been blessed with three children: 2 boys and a daughter. Her husband is a mechanic at a nearby tea factory. M.L. denies consuming cigarettes, alcohol, or illicit substances like heroin and cocaine.
She states that the family diet comprises of directly cooked foods and denies consuming processed foods. M.L. denies doing exercise or being part of a community exercise program. According to M.L., her husband is the sole bread winner of the family. They spend the little income he is getting from his job to acquire basic needs and pay medical bills. She is sexually active and reports being faithful to her husband.
Genera
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