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Musculoskeletal SOAP Note Rheumatoid Arthritis

📅 March 23, 2026 ✍️ Best Essay Pros ⏱ 12 min read

Assessment 2: Focused Musculoskeletal SOAP Note – Shadow Health “Shoshanna Tillman” Case

Unit/Course Overview

This assessment is set in the Shadow Health virtual clinic and uses the standardized patient case of Shoshanna Tillman, a 39‑year‑old woman presenting for a sick follow‑up visit with joint pain and fatigue. You are expected to demonstrate advanced health assessment, clinical reasoning, and documentation skills for a musculoskeletal presentation that may reflect early rheumatoid arthritis or another chronic pain syndrome. The task aligns with current MSN/FNP and advanced health assessment assignments that require students to generate a formal SOAP note after completing the Shadow Health digital clinical experience. Your work should integrate current evidence, relevant differential diagnoses, and a safe, patient‑centred plan of care. [studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

Assessment Details

  • Assessment title: Focused Musculoskeletal SOAP Note – Shadow Health “Shoshanna Tillman”
  • Course level: Upper‑division BSN / graduate nursing (FNP/AGNP/Advanced Assessment)
  • Assessment number: Assessment 2 (or Task 2) – Clinical Documentation
  • Weighting: 25–30% of overall unit grade (program dependent)
  • Length: 1,050–1,400‑word focused SOAP note (approximately 3–4 double‑spaced pages)
  • Mode: Individual written assignment
  • Format: Structured SOAP note + brief evidence summary, APA 7th referencing

Case Context

You will complete the Shadow Health Digital Clinical Experience for the follow‑up sick visit of Ms. Shoshanna Tillman, who reports persistent joint pain, stiffness, and fatigue over the past three months, with symptoms affecting her hands, wrists, and overall functioning. In the virtual encounter, you will collect a focused history, perform an appropriate musculoskeletal and relevant system examination, and review any available results or documentation. Your written submission will then translate this encounter into a concise, clinically credible SOAP note that could be used in a real outpatient setting. [nursinghero](https://www.nursinghero.com/study-files/16769885)

Assessment Task

Compose a 1,050–1,400‑word focused musculoskeletal SOAP note for Ms. Shoshanna Tillman’s Shadow Health visit, followed by a short evidence paragraph that justifies your primary diagnosis and plan. Use the information you obtain during your Shadow Health session (history, exam findings, and any available objective data) to build a coherent, accurate record. Your documentation must show logical diagnostic reasoning around possible causes of her joint pain and fatigue, with a particular focus on differentiating early rheumatoid arthritis from other musculoskeletal conditions. [sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)

Specific Requirements

  1. Subjective (S)
      • Chief complaint in the patient’s own words.
      • History of present illness (HPI) using a structured approach (e.g. OLDCARTS: onset, location, duration, character, aggravating/relieving factors, timing, severity), including fatigue, joint pain pattern, morning stiffness, functional impact, and medication response.

    [cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

      • Relevant review of systems (ROS) for musculoskeletal, constitutional, neurological, integumentary, and any red‑flag symptoms (e.g. fevers, weight loss, systemic features).

    [studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

      • Brief psychosocial history and risk factors (occupational demands, stress, family history of autoimmune disease, lifestyle factors).

    [cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

  2. Objective (O)
      • Vital signs and general appearance, where available from the Shadow Health report.

    [sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)

      • Focused musculoskeletal examination of hands and wrists, including inspection, palpation, range of motion, strength, and any deformities or swelling.
      • Interpretation of special tests that are performed in the case (e.g. Tinel’s, Phalen’s, Finkelstein’s) to help rule in or rule out conditions such as carpal tunnel syndrome or De Quervain’s tenosynovitis.

    [studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

      • Other relevant systems examined (cardiovascular, respiratory, neurological, skin) that support or refute your differential diagnoses.

    [sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)

  3. Assessment (A)
      • Identify a primary working diagnosis that best explains Ms. Tillman’s presentation (e.g. early rheumatoid arthritis, unspecified), referencing current diagnostic criteria where appropriate.

    [cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

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      • List two to three differential diagnoses with brief rationales (for example: osteoarthritis, fibromyalgia, hypothyroidism, or other connective tissue disease), explicitly linking them to, or distinguishing them from, the patient’s symptoms and examination findings.

    [studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

      • Include relevant ICD‑10 codes for the primary diagnosis and key differentials where available.

    [cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

  4. Plan (P)
      • Pharmacologic management: discuss NSAID use (e.g. diclofenac) and adjustments if indicated, plus any disease‑modifying or adjunctive agents that may be considered in collaboration with rheumatology and in accordance with current guidelines.

    [studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

      • Non‑pharmacologic interventions: joint protection strategies, activity modification, heat/cold, referral to physical or occupational therapy when appropriate.

    [sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)

      • Diagnostics: recommend initial investigations, such as ESR/CRP, rheumatoid factor, anti‑CCP antibodies, and relevant imaging, and justify why they are indicated at this stage.

    [cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

      • Patient education and self‑management, including safety netting (worsening symptoms, red flags, follow‑up timeframe) and counselling around stress, fatigue, and daily functioning.

    [sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)

    • Follow‑up plan with clear timing and specific review goals.
  5. Evidence support paragraph
      • After the SOAP sections, add a 150–200‑word paragraph that briefly summarises the reasoning for your primary diagnosis and plan, using at least one current peer‑reviewed source or clinical guideline to support your decisions.

    [studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

    • Use APA 7th in‑text citation and reference list at the end of the assignment.

Formatting and Submission

  • Length: 1,050–1,400 words, excluding reference list.
  • Formatting: 12‑point font, double spacing, standard margins, headings for SOAP sections.
  • Referencing: APA 7th edition; minimum of 3–5 current scholarly sources (2018–2026).
  • File type: Word document or PDF, submitted via the LMS assessment portal by the due date.
  • Include the Shadow Health attempt ID or transcript summary page as an appendix if required by your program.

Marking Criteria / Rubric

Rubric Table

[nursinghero](https://www.nursinghero.com/study-files/16769885)[sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)
[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)
[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)
[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)
[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)[studocu](https://www.studocu.com/row/document/university-of-nairobi/material-science/soap-note-musculoskeletal/85179176)

Criterion High Distinction / A (85–100%) Credit / B (65–74%) Pass / C (50–64%) Fail / F (<50%)
Subjective data (S) Comprehensive, focused HPI and ROS that capture all key musculoskeletal and fatigue‑related details; information is well organised, accurate, and clearly linked to the presenting complaint. Adequate HPI and ROS with most relevant details; minor omissions or limited depth in some areas, but overall coherent and appropriate to the case. Basic HPI and ROS; several important elements are missing or under‑developed; focus may be inconsistent or descriptive rather than clinically analytical. Subjective data are incomplete, inaccurate, or poorly focused; major gaps that compromise clinical reasoning.
Objective data (O) Thorough, accurate documentation of focused examination findings, including relevant musculoskeletal tests, vital signs, and pertinent positives/negatives; clearly supports later diagnostic reasoning. Generally accurate and appropriate objective data; some details or pertinent negatives may be missing but core exam findings are present. Limited or partially inaccurate objective data; key exam components or negative findings not recorded, reducing interpretability. Objective section is absent or largely inaccurate; fails to reflect the Shadow Health encounter.
Assessment and differential diagnosis Primary diagnosis is clinically plausible and well justified using history and exam findings; two to three differentials are clearly explained with succinct rationales that reference current evidence or criteria. Primary diagnosis is reasonable, with some justification; differentials are relevant but rationales may be brief or partially developed. Primary diagnosis is loosely linked to data; differentials are superficial or not clearly distinguished from one another. Assessment is unsupported, inconsistent with case data, or missing; differential diagnoses not identified or not plausible.
Plan (management, diagnostics, education) Management plan is safe, evidence‑based, and appropriately detailed across pharmacologic, non‑pharmacologic, diagnostic, and education components; follow‑up arrangements are explicit and realistic. Plan is generally appropriate and safe, with some evidence of prioritisation; minor omissions in detail or justification. Plan addresses basic elements but lacks depth, specificity, or rationale; may be partly generic or not fully tailored to Ms. Tillman. Plan is unsafe, vague, or largely absent; does not reflect current practice standards.
Use of evidence and guidelines Integrates up‑to‑date clinical evidence or guidelines to support key decisions in diagnosis and management, with accurate APA 7th citation and referencing. Uses some relevant evidence, though integration may be limited to one section or not fully critical; referencing mostly accurate. Minimal or outdated evidence; limited connection between sources and clinical decisions; referencing inconsistent. No identifiable use of credible evidence or guidelines; referencing missing or incorrect.
Organisation, clarity, and academic writing SOAP note format is followed precisely; writing is clear, concise, and logically structured; grammar, spelling, and academic tone are of publication‑ready quality. Mostly well structured with minor lapses in clarity or formatting; occasional language errors that do not impede understanding. Organisation is uneven; frequent language errors and formatting issues that detract from clarity. Disorganised, difficult to follow, or off‑format; frequent errors that significantly reduce readability.

Sample Answer Content

In Ms. Shoshanna Tillman’s case, the combination of chronic symmetric pain and stiffness in the small joints of the hands and wrists, morning functional difficulty, and low‑grade fatigue strongly suggests an early inflammatory arthritis rather than a purely degenerative process. Her symptoms have persisted for around three months and have a global impact on daily activities such as holding a coffee cup, typing, and using art tools, which fits with rheumatoid arthritis patterns described in current primary care texts. The physical examination that shows tenderness at the proximal interphalangeal joints, normal sensory testing, and negative Tinel, Phalen, and Finkelstein tests helps to rule out carpal tunnel syndrome and De Quervain’s tenosynovitis while keeping inflammatory polyarthritis high on the list. A focused diagnostic work‑up with ESR, CRP, rheumatoid factor, and anti‑CCP antibodies can clarify the degree of systemic inflammation and support early rheumatology referral, since prompt initiation of disease‑modifying therapy may prevent joint damage and long‑term disability. Alongside pharmacologic management, it is reasonable to emphasise joint protection, heat therapy, pacing of activities, and support for coping with ongoing fatigue so that Ms. Tillman can maintain her roles and quality of life while a definitive diagnosis is confirmed. [nursinghero](https://www.nursinghero.com/study-files/16769885)

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A well‑structured SOAP note for this Shadow Health musculoskeletal case usually ties the narrative history to specific exam findings and then uses that data trail to justify each item in the differential diagnosis list. Students who perform strongly tend to document pertinent negatives explicitly, such as the absence of neurological deficits, overt joint deformities, or systemic signs that might redirect the assessment toward infection or malignancy, and they link their management decisions to guidelines for early rheumatoid arthritis and chronic pain in primary care. It is also useful to acknowledge uncertainty around evolving autoimmune disease and to outline a stepwise plan that includes monitoring, patient education, and timely referral rather than assuming the diagnosis is fixed after one encounter. In many programs, markers of high‑quality work include consistent APA referencing, clear clinical language, and realistic short‑term and long‑term goals that could be implemented in a real clinic. [studocu](https://www.studocu.com/en-us/document/william-paterson-university/advanced-nursing-ii/shadow-health-digital-clinical-experiences-from-elsevier/125175790)

Suggested Next Assessment: Discussion Post – Chronic Joint Pain and Early Referral

Title: Week 5 Discussion: Early Identification and Referral in Chronic Joint Pain

Task: In a 300–400‑word initial discussion post, analyse how primary care clinicians should approach early recognition and referral of patients with suspected inflammatory arthritis who present with non‑specific joint pain and fatigue, using Ms. Shoshanna Tillman as an example case. Draw on current evidence or guidelines to discuss when it is appropriate to continue conservative care in primary care and when specialist referral should be initiated, and comment briefly on how telehealth or digital simulations like Shadow Health can support clinical decision‑making. Respond to at least two peers (150–200 words each) by comparing referral thresholds, highlighting similarities and differences in interpretation of red flags and system constraints in your local practice setting. [studocu](https://www.studocu.com/en-us/document/william-paterson-university/advanced-nursing-ii/shadow-health-digital-clinical-experiences-from-elsevier/125175790)

Potential STUDY TOPICS Titles

  1. Shadow Health SOAP Note Example for Shoshanna Tillman Joint Pain and Fatigue
  2. Musculoskeletal SOAP Note Rheumatoid Arthritis
  3. Shoshanna Tillman Shadow Health Musculoskeletal SOAP Assignment Guide
  4. Writing a Focused SOAP Note for Joint Pain and Fatigue in Shadow Health
  5. How to Document the Shoshanna Tillman Musculoskeletal Shadow Health Case

 

 References (APA 7th)

    • Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg‑Cook, J. (2021). Primary care: A collaborative practice (6th ed.). Elsevier. https://doi.org/10.1016/C2018-0-00792-4

[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

    • Curtis, J. R., Xie, F., Chen, L., Spettell, C., McMahan, R. M., & Singh, J. A. (2020). Clinical outcomes in patients with rheumatoid arthritis starting biologic and targeted synthetic DMARDs: A real‑world study. Arthritis Care & Research, 72(10), 1407–1416. https://doi.org/10.1002/acr.24164

[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

    • Hollier, A. (2021). Clinical guidelines in primary care (4th ed.). Advanced Practice Education Associates. (Often cited in Shadow Health SOAP note exemplars for musculoskeletal cases.)

[sweetstudy](https://www.sweetstudy.com/questions/see-below-20790101)

    • Smolen, J. S., Aletaha, D., McInnes, I. B. (2018). Rheumatoid arthritis. Lancet, 388(10055), 2023–2038. https://doi.org/10.1016/S0140-6736(16)30173-8

[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

    • Fraenkel, L., Bathon, J. M., England, B. R., St. Clair, E. W., Arayssi, T., Carandang, K., et al. (2021). 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis & Rheumatology, 73(7), 1108–1123. https://doi.org/10.1002/art.41752

[cliffsnotes](https://www.cliffsnotes.com/study-notes/33125800)

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Related Topics:

#advanced health assessment SOAP note#musculoskeletal joint pain fatigue assignment#rheumatoid arthritis focused exam nursing#Shadow Health musculoskeletal documentation example#Shadow Health Shoshanna Tillman SOAP note

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