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SOAP NOTE: From Contingency Plan: Aquifer Family Medicine 11: 74-Year-Old Female with
Knee Pain
Name: Ms. Roman Date: 6/18/2020 Time: 0900
Age: 74 Sex: Female
SUBJECTIVE
CC:
"I've been having some pain in my right knee. It's really been bothering me. It feels achy
all over. I've had knee pain off and on for months, but it has become more constant for the
last several weeks. When the pain didn't seem to be going away, I decided to come see the
doctor."
HPI:
The patient is a 74-year-old Caucasian female who presents to the doctor’s office today
with the chief complaint of right knee pain. She has reports that the knee pain has been
intermittent for months, but has become more constant over the past several weeks. She
has had no injuries, and no past surgeries, but does report that she “hits her knee” while
gardening sometimes. She reports the pain as a 6 on a scale of 0-10, and reports it as a
“grinding” pain. She has some decreased range of motion and crepitus with moving the
right knee. The pain gets better with rest, and worse throughout the day with activity.
Bengay also helps with the knee pain, but she reports she has not tried to take any oral
medications.
Medications: (list with reason for med )
Multivitamin
Extra-strength Tylenol (PRN for pain)
Tums (PRN for heartburn)
PMH
GERD (patient controls with PRN Tums) Alcohol Use Disorder Allergies: NKDA Medication Intolerances:
N/A
Chronic Illnesses/Major traumas This patient is a 74-year-old female with a history of GERD and remote history of alcohol use disorder. She takes no prescription drugs at home, only TUMS for heartburn, Tylenol PRN for pain, and a multivitamin. She has no chronic illnesses, and has had no major hospitalizations. The only surgery she has had was a tonsillectomy as a child. She has had no major traumas. Hospitalizations/Surgeries
Tonsillectomy
Family History Mother - Diabetes Mellitus Type 2 Osteoarthritis Father – “Skin Problems” Social History Tobacco: Nonsmoker ETOH: None – Reports she has not had a drink in several years Illicit Drugs: None Caffeine: 0 cups of caffeine per day. Occupation: Retired School Teacher lives alone in a two-story home in a rural community. Her hobby is gardening, which she enjoys daily. ROS General The patient is a thin, well-groomed Caucasian female. Her hair and clothes are clean and appropriate. She appears to appropriate age. Cardiovascular The patient’s heart rhythm is regular upon assessment. She has normal S1 and S2 heart sounds, no S3, S4 no heart murmur, lifts, heaves, or thrills. Reports no chest pain Blood Pressure: 130/80 HR: 64 Skin The patient’s skin in clean, warm, dry, and intact. The color is appropriate for ethnicity.. No bruising or open wounds noted to skin. Respiratory Patient has no wheezing, shortness of breath, or cough noted. Lung sounds are clear to auscultation bilaterally.
HEENT
HEAD: The patient’s head is normocephalic, and hair is evenly distributed throughout the scalp. The hair and scalp is clean. There are no rashes or lesions on the head or scalp. EYES: PERRLA. No double vision, or changes in vision. There is no drainage from the eyes. The patient’s sclera is white. EARS: The patient’s ears are intact. No tinnitus or trouble hearing. She has no drainage from her ears. Tympanic membrane is pearly white and intact. NOSE: The patient’s nasal mucosa is intact and pink. Her nasal turbinates are WNL. She denies any nasal congestion or drainage. The patient has no septal deviation. NECK: the patient has full range of motion of the neck. Denies any neck stiffness. Lymph nodes are not palpable. There is no JVD or thyromegaly. THROAT: The patient denies any throat pain. The oral mucosa is intact, pink and moist. Her teeth are clean and intact. There is no inflammation or drainage. . Cardiovascular The patient’s heart rhythm is regular upon assessment. She has normal S1 and S2 heart sounds, no S3, S no heart murmur, lifts, heaves, or thrills. Reports no chest pain Blood Pressure: 130/80 HR: 64 Respiratory Patient has no wheezing, shortness of breath, or cough noted. Lung sounds are clear to auscultation bilaterally. Respiratory Rate: 18 breaths/minute Gastrointestinal The patient’s abdomen is soft and nontender with no masses noted with palpitation. He has no complaints with black, tarry stools, nausea, vomiting, or diarrhea. She has active bowel sounds in all 4 quadrants. Breast The patient’s chest is flat without tenderness, lumps, masses, or discharge. The nipples are intact Genitourinary Unremarkable. Patient has no complaints of urinary frequency, urgency, or pain/discomfort with urinating. Her bladder is non-distended. No masses or lesions in the groin area. The bladder is non distended. No CVA tenderness. Musculoskeletal Patient complains of pain in right knee. She has some tenderness in the joints of her right leg with palpation. ROM is 120 degrees in her right leg. She does have some crepitus in right patellar with movement. Normal range of motion with hips and ankles. Positive lower back pain. Neurological Patient is alert and oriented x4. Patient’s cranial nerves intact. She has full strength in bilateral upper and lower extremities. Sensation grossly intact. His speech is clear. Patient denies any headaches or blurred vision. Psychiatric The patient is oriented to person, place, and situation. She denies any hallucinations or delusions. Reports no feelings of sadness, depression, or feelings of hopelessness. Lab Tests *No lab tests ordered for this patient Special Tests
Knee Exam
Imaging Diagnosis Differential Diagnoses o 1 - S83- Dislocation and sprain of joints and ligaments of knee
Lacheman Test Negative
McMurray Test Negative
- Participate in cardiovascular (aerobic) and/or resistance exercise, either aquatic or land-based
- Lose weight (for patients who are overweight)
- Participate in self-management programs, typically guided by a physical therapist (Aquifer, n.d)
- Assistive Devices: Canes, walkers, raised toilet seats, and other assistive devices can make performing daily activities easier by reducing stress on joints Evaluation of patient encounter: This patient is a 74-year-old Caucasian female who presented to the doctor’s office with chief complaint of right knee pain. The patient has been having the knee pain for months, but it has become more constant over the past several weeks. The patient has no history of trauma to the knee and there was crepitus to the patient’s right knee during her exam. The patient was diagnosed with Osteoarthritis, which symptoms are Chronic joint stiffness and pain, Crepitus on exam, and Mild or no joint effusion. The Initial Management: - Bengay - Apply a thin layer of medication to the affected area no more than 3 to 4 times a day. Rub in gently and thoroughly.
- Tylenol – 325 – 650 mg q 4 hours PRN for mild pain. Do not exceed 4g/day
- Paracematol 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours orally or rectally.
- An exercise plan to decrease BMI Ms. Roman is continually educated about osteoarthritis, and given other options, such as if she does not get any better with the treatment options she has now, she can possibly start taking NSAIDs (not recommended because of the side effects) or she can get intra-articular steroid injections (Aquifer, n.d).
References
Aquifer. (n.d). Family Medicine 11: 74 - year-old female with knee pain. Retrieved from
https://southu-nur.meduapp.com/document_set_document_relations/
Osteoarthritis. (n.d.). Retrieved from https://www.uptodate.com/contents/osteoarthritis-
treatment-beyond-the-basics
Rochester Medical Center. (n.d). Osteoarthritis. Retrieved from
https://www.urmc.rochester.edu/encyclopedia/content.aspx?
contenttypeid=85&contentid=p
