Unit 7 SOAP Note

Instructions

Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 15-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a 0 will be input into the Grade Center as a place holder until you have submitted the required assignment.

Patient Information:

Patient: 64-year-old male

Chief Complaint: My left knee has been hurting for a few weeks.

Subjective

HPI:

64-year-old male presents with complaints of left knee pain for approximately 4 weeks. Patient reports gradual onset without known trauma or injury. Pain is described as a deep, aching sensation localized to the medial aspect of the left knee. Pain is rated 6/10 at worst and 3/10 at rest. Symptoms are worse with prolonged walking, climbing stairs, and rising from a seated position. Reports morning stiffness lasting approximately 2030 minutes. Denies locking, catching, or instability. Mild intermittent swelling noted. Denies redness, warmth, fever, recent illness, or calf pain.

Has tried OTC ibuprofen with partial relief.

Past Medical History:

• Hypertension
• Hyperlipidemia
• Type 2 Diabetes Mellitus

Medications:

• Lisinopril 20 mg daily
• Atorvastatin 20 mg nightly
• Metformin 1000 mg BID
• OTC ibuprofen PRN

Allergies: NKDA

Past Surgical History: None related to knee

Family History:

• Father: Osteoarthritis
• Mother: Type 2 DM

Social History:

• Retired
• Former smoker (quit 10 years ago)
• Occasional alcohol
• BMI: 31

Review of Systems:

• Constitutional: Denies fever, weight loss
• Musculoskeletal: Left knee pain and stiffness; denies other joint pain
• Neurological: Denies weakness or numbness
• Skin: Denies rash

Objective

Vital Signs:

BP: 132/78

HR: 72

RR: 16

Temp: 98.2F

BMI: 31

General: Alert, oriented 3, no acute distress

Musculoskeletal:

• Inspection: Mild swelling left knee, no erythema
• Palpation: Tenderness over medial joint line
• ROM: Slightly decreased flexion secondary to pain
• Crepitus noted with movement
• Negative anterior/posterior drawer
• Negative Lachman
• No varus/valgus instability
• Gait: Mild antalgic gait

Neurovascular:

• Sensation intact
• Pedal pulses 2+ bilaterally

Assessment

Primary Diagnosis:

• Likely Primary Osteoarthritis of Left Knee

Osteoarthritis

Differential Diagnoses:

• Medial meniscus tear
• Patellofemoral pain syndrome
• Inflammatory arthritis
• Gout
• Septic arthritis (low suspicion)

Plan

Diagnostics:

• X-ray left knee (AP, lateral, sunrise views)
• Consider MRI if mechanical symptoms develop

Medications:

• Continue NSAIDs PRN (educate on GI and renal precautions)
• Consider topical diclofenac gel
• Consider acetaminophen for pain control

Non-Pharmacologic:

• Weight loss counseling
• Physical therapy referral
• Quadriceps strengthening exercises
• Low-impact exercise (swimming, cycling)
• Knee brace if beneficial

Education:

• Discussed degenerative nature of osteoarthritis
• Encouraged glycemic control to reduce inflammation burden
• Reviewed red flag symptoms (increased swelling, redness, fever, inability to bear weight)

Follow-Up:

• Return in 46 weeks
• Sooner if worsening symptoms