soap 3

SOAP2Feedback.pdf

SOAP Note Template

Encounter date: 3/22/2022_______

Patient Initials: __QNC____ Gender: M/F/Transgender __M__ Age: __70___ Race: __Caucasian___ Ethnicity _Non-Hispanic___

Reason for Seeking Health Care: “ I have been experiencing pain in my two legs” HPI: QNC is a 70-year-old Non-Hispanic Caucasian male patient who visits the facility with the complaint of painful legs. He reported that the pain is 7/10 and reported past surgeries on both knees. The first surgery was done on the left leg in the last 20 years as a result of a sports injury while the other surgery on the right knee was done 15 years ago. He reported ongoing stabs of pain and has been using Percocet for the management of the pain. He admits that the pains worsen with weather changes. He dines the shortness of breasts, pressure, discomfort or chest pain, and headache.

Allergies(Drug/Food/Latex/Environmental/Herbal): she reported being allergic to NSAIDs since they cause more pain in her abdomen Current perception of Health: Good

Past Medical History � Major/Chronic Illnesses: depression, osteoarthritis, paining joints, and high blood

pressure. � Trauma/Injury: reported only sports injuries he had. � Hospitalizations: denies any history of hospitalization

Past Surgical History: underwent an operation on the knee and the injured legs 20 years ago.

Medications: he is on vitamin D, Percocet oral tablet 10-325 mg, Mirtazapine 7.5 mg OD for 3 months, and Lipitor tablet 20 mg OD for 3 months.

Family History: Father is deceased after diagnosis with hypertension. Mother is also deceased

and was diagnosed with hyperlipidemia

Social history:

Lives: Single-family house Marital Status: Married Employment Status: _retied

Current/Previous occupation type: _Farmer

Exposure to: ___ denies smoking but admits taking alcohol once in a

week__Recreational Drug Use: denies

Sexual orientation: ___heterosexual and married to a wife with two children____

Sexual Activity: _active and has one partner as a wife Contraception Use: __Not

Applicable in this case__________

Family Composition: Family/Mother/Father/Alone: _Living with the wife and the two

children___

Health Maintenance

Screening Tests: Admits having colonoscopy and PSA and revealed normal results

Exposures: denies exposure to toxic chemical

Immunization HX: up to date recently with the COVID-19 vaccine

Review of Systems:

General: denies fever, chills, changes in the body weight, and night sweats

HEENT: denies tenderness or abnormality of the head; no changes in vision or hearing.

Neck: denies injuries, stiffness, or neck tenderness.

Lungs: reported no coughs, wheezes, and shortness of breath.

Cardiovascular: denies the pressure, discomfort, and pain in the chest

Breast: denies tenderness and pain or discharges

GI: denies diarrhea, vomiting, and abdominal pain or nausea. Denies changes in appetite.

Male/female genital denies penile discharges, pain during urination, or hematuria.

GU: denies urgency and frequent urination. Denies burning sensation and pain during urination

Neuro: reported no syncope or headache

Musculoskeletal: admits bilateral pain in the knee

Activity & Exercise denies intolerance to exercise or activity

Psychosocial: denies anxiety or depression or changes in the mood

Derm: denies rashes, changes in the skin color, or lesions

Nutrition: denies consumption of a balanced diet and changes in the appetite

Sleep/Rest admits normal sleeping and resting patterns

LMP: No Applicable

STI Hx: denies any history of STIs.

Physical Exam

BP___120/70_____TPR_37.8____ HR: __80___ RR: _16___Ht. _5 8’’____ Wt. __190____

BMI (percentile) _26.8____

General: he appears overweight, elder, and non-Hispanic Caucasian male with no chronic

distress

HEENT: there isane atraumatic and normocephalic head with no symptoms of the lesions. The

eye has normal pupils that are reactive to light and white sclera and conjunctiva. There is an

absence of the cerumen in the external auditory meatus.

Neck: no deviation or palpable nodes.

Pulmonary: there is a regular rhythm rate in the S1 and S2. Non-labored respiration

Cardiovascular: there is audible S1 and S2 with absence of heart sounds.

Breast: the masses, scars, or changes are absent in the color of the nipple

GI: there is normal bowel movement. There is soft, non-tender, and lack of organomegaly on

deeper palpation.

Male/female genital: even distribution of hair in the pubic parts and no penile discharges.

GU: no tenderness or pain on palpation

Neuro: there is intact cranial nerves and the ability to coordinate. Normal sensation in all the

dermatomes

Musculoskeletal: there is bilateral tenderness of the knees on palpitation

Derm: warm to touch skin with the normal skin color representing Caucasian Descent. There is a

presence of surgical scars on the knees

Psychosocial: energetic, alert, and oriented to person, place, and time. There is coherent speech

and the ability to maintain eye contact.

Misc. No abnormal findings

Plan:

Differential Diagnoses

1. Bursitis (M71.50)

2. Patellofemoral syndrome (M22.2X1)

3. Chondromalacia (M22.40)

Principal Diagnoses

1. Chronic knee pain (M25.569) bilateral leg with pain on a scale of 7/10

2. Osteoarthritis (M19.90) bilateral leg with pain on a scale of 7/10

Plan

Diagnosis: Chronic Knee Pain

Diagnostic Testing: Pain scale and the examination of the musculoskeletal

Pharmacological Treatment: the patient to continue on Percocet oral tablet after every 6 hours

PRN for the next 30 days

Education: counseling on physical activity and nutrition

Significant data/contributing

Screening for depression on 1/1/2022 PHQ score of 0

X/laboratory Test/Misc: MRI and X-ray

Referrals: referred to the rheumatologists

Follow-up: the follow-up process starts 4 weeks later

Anticipatory Guidance: the patient to adhere to the instructions of the provider and take

medications appropriately.

Diagnosis: Osteoarthritis

Diagnostic Testing: The MRI and the X-ray procedure

Pharmacological Treatment: he is started on medication of celecoxib 200 mg PO 1 tablet BID

for the next 4 weeks.

Education: advised on the importance of nutrition and physical activity.

Referrals: rheumatologist

Follow-up: 4 weeks after discharge

Anticipatory Guidance: adherence to the medication prescribed

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)________QNC______________________ Age ___70________

Date: ___30/1/2022____________

RX ____ celecoxib __________________________________

SIG: 200 mg PO 1 tablet BID for 4 weeks

Dispense: ___56________ Refill: ________0_________

No Substitution

Signature: ____________________________________________________________

References

Cleveland, R. J., Alvarez, C., Schwartz, T. A., Losina, E., Renner, J. B., Jordan, J. M., &

Callahan, L. F. (2019). The impact of painful knee osteoarthritis on mortality: a

community-based cohort study with over 24 years of follow-up. Osteoarthritis and

cartilage, 27(4), 593-602. https://doi.org/10.1016/j.joca.2018.12.008

Iijima, H., Aoyama, T., Fukutani, N., Isho, T., Yamamoto, Y., Hiraoka, M., ... & Matsuda, S.

(2018). Psychological health is associated with knee pain and physical function in

patients with knee osteoarthritis: an exploratory cross-sectional study. BMC

psychology, 6(1), 1-10. https://doi.org/10.1186/s40359-018-0234-3

Taylor, N. (2018). Nonsurgical management of osteoarthritis knee pain in the older adult: an

update. Rheumatic Disease Clinics, 44(3), 513-524.

DOI:https://doi.org/10.1016/j.rdc.2018.03.009