Shoshanna Tillman Musculoskeletal SOAP Note | Shadow Health Follow-Up [2026 Verified A+]

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Shoshanna Tillman Musculoskeletal SOAP Note | Shadow Health Follow-Up [2026 Verified A+] HPI: Shoshanna Tillman is a 39-year-old white female who presents to the clinic complaining of fatigue and joint pain. She says she first noticed the joint pain around three months ago, and has persisted ever since. Her hands and wrists feel the brunt of the agony, but she is also experiencing widespread discomfort. Pain in Mrs. Tillman's wrists and hands is dull, throbbing, and stiff, and it seems to be worse in the morning. She rates her current pain as 2 out of 10. She says that hot baths and the pain reliever Diclofenac have helped her considerably with her joint discomfort. She also says that sitting for long periods or working with her hands makes her joints hurt worse. Before starting Diclofenac, she would rate her pain as a 3 or 4 out of 10. Mrs. Tillman's chronic weariness and joint discomfort appeared around three months ago. She feels more tired during the day but cannot pinpoint any particular triggers or remedies. She has lost weight, has not had much appetite, and has had sporadic bouts of fever throughout the previous month. Despite her symptoms, She can go on with her everyday life, albeit she feels "drained" afterward, and things take longer than normal.

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