Soapnote on musculoskeletal

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Soapnote on Unilateral Primary Osteoarthritis, right knee

Student’s Name

Institutional Affiliation

Course Name and Number

Instructor’s Name

Date

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Soapnote on Unilateral Primary Osteoarthritis, right knee

Name: Date: Time: Age: 74 Sex: Female SUBJECTIVE CC: “I have pain and inflammation in my right knee.” HPI: A 74 year old Hispanic female presents to the office with complains of pain and

inflammation on her right knee. The patient states that her symptoms started about 7

months ago and they have been worsening as time goes by. The patient also states that

she has been experiencing loss of flexibility, stiffness, tenderness and grating sensation of

right knee when walking. The patient adds that she noticed her symptoms got worse after

adding five pounds. The patient describes her pain as sharp and rates it as 7/10 and adds

that this condition is making causing her to have limited range of motion. The patient

states that her condition gets worse with activities and goes away when resting. The

patient also reports that she feels stiffness after awakening from rest or in the morning.

The patient reports that she was diagnosed with obesity 2 years ago and she manages her

condition with medication. The patient denies being diagnosed with other chronic

ailments. The patient state that she sometimes takes ibuprofen medication to relieve her

symptoms but the effect of the medication is so small compared to her pain. Medications:

Ibuprofen (Rx OTC) 300mg PO q6-8hr for pain.

Orlistat (Alli) 60 mg PO q8hr with each fat containing meal for obesity. PMH

Medication Intolerances: None.

Major traumas: None.

Chronic Illnesses: Obesity

Hospitalizations/Surgeries: None.

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Allergies: No known allergies. Family History: The patient reports that her father and paternal grandparents had

diabetes and adds that his father was diagnosed with osteoarthritis before dying about 20

years ago. The patient states that her mother died of a road accident but did not have any

underlying health condition. The patient states that he has a daughter and a son and his

son is obese. Social History: The patient is a retired social worker and she holds a degree in sociology.

The patient is married and lives with her husband in a safe and quiet environment in an

upcountry house. The patient denies ever smoking, drinking alcohol and using any

recreational substance. The patient states that she loves playing piano in the evening with

her husband. ROS General: Denies night sweats, fatigue,

chills, fever, unplanned weight gain or

body aches.

Cardiovascular: Denies palpitation, PND,

tachycardia, chest pressure and edema.

Skin: Denies changes in color, turgor and

lesions, bruises or rashes.

Respiratory: Denies TB, wheezing,

coughing, pneumonia hx and dyspnea. Eyes: Denies blurriness, pain, double

vision or use of corrective lenses.

Gastrointestinal: Denies constipation,

black-tarry, eating disorders, nausea,

vomiting or abdominal pain. Ears: Denies pain, discharge or hearing

loss.

Genitourinary/Gynecological: Denies

unusual vaginal discharge, urination

urgency or burning sensation on urination. Nose/Mouth/Throat: Denies nose bleeds,

runny nose, congestion, throat pain and

hoarseness.

Musculoskeletal: Reports pain,

inflammation, loss of flexibility, stiffness,

tenderness and grating sensation of right on

the right knee. Denies muscle pain.

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Breast: Denies tenderness, lumps or

masses.

Neurological: Denies transient paralysis,

syncope, headache, black-out spells or

seizures. Heme/Lymph/Endo: Denies swollen

glands, cold or heat intolerance and blood

transfusion hx.

Psychiatric: Denies anxiety, suicidal

thoughts, sleeping difficulty or depression.

OBJECTIVE Weight: 197lbs BMI:

30kg/m2

Temp: 98.1lbs BP: 120/80

Height: 5’ 8” Pulse: 78 Resp: 16 General Appearance: The patient looks healthy and appears to be experiencing mild

distress. She is wearing clean clothes which are in line with the prevailing weather. Skin: Dry, soft with no cracks, lesions or bruises. No changes to the skin color or turgor

observed. HEENT: Head is head is atraumatic normocephalic with evenly distributed and

moisturized hair. PERRLA. Intact EOMs. Easily visualized landmarks, patent canals. No

congestion or discharge observed, no septal deviation. Pink oral mucosa. Neck supple

with full range of motion. Cardiovascular: No murmurs, extra sounds, gallops or rubs. Regular rate and rhythm

with S1 and S2. Pulses 3+ throughout. Capillary refills in 2 seconds. Respiratory: Lungs clear to auscultation. Regular and easy respirations with no chest

wall abnormalities. Gastrointestinal: Soft and non-tender abdomen. Normal active-bowel sounds heard in

all four quadrants. Breast: No tenderness, masses or lumps noted on the palpitation of the breasts. Genitourinary: The patient has no gynecological disorders. Musculoskeletal: Crepitus noted as the patient walks around the exam room. Warm

swollen right knee with limited range of motion noted on the right knee. Tenderness

noted on palpitation of the right knee. Neurological: Erect posture, clear speech, good tone, normal gait and stable balance.

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Psychiatric: The patient is alert and oriented to place, time and people, cooperative and

answers all the questions as expected. Lab Tests

X-ray of the right knee: Joint space narrowing, subchondral sclerosis and osteophytes

observed.

ESR: Normal.

Serum CRP: Normal.

MRI of the right knee: Bone marrow lesions, cartilage loss and meniscal tears.

Rheumatoid factor, RF: Negative.

Anti-CCP: Negative. Special Tests

None Diagnosis Differential Diagnosis:

M06. 9 - Rheumatoid arthritis, unspecified: This is a chronic inflammatory medical

disorder that affects the blood vessels, eyes, lungs and joints (Burmester & Pope, 2017).

Rheumatoid arthritis is characterized by loss of appetite, joint stiffness, fatigue and

swollen joints. The patient only complained of joint stiffness and swollen joints and not

the other symptoms associated with rheumatoid arthritis making this diagnosis less likely.

The diagnostic and lab results eliminated the condition as the diagnosis.

M10.9 – Gout, unspecified: This is an arthritis that is associated with the stiffness, intense

pain and swelling of the joints (Ragab et al., 2017). The condition is associated with

symptoms such as limited ROM, lingering discomfort, intense joint pain and

inflammation of the joint (Ragab et al., 2017). The condition presents with symptoms that

occur suddenly and mostly at night. The patient presented with these symptoms but did

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not state that they occur suddenly at time. The history, physical exam and ordered lab

tests ruled out gout as the diagnosis.

M70. 41 - Prepatellar bursitis, right knee: This is a condition that is characterized by the

inflammation of the bursa in the patella (Sato & Watari, 2020). The condition develops

when the bursa produces too much fluid due to irritation causing swelling. The condition

is characterized by tenderness, rapid swelling on the kneecap from and pain with activity

(Sato & Watari, 2020). The patient reported all these symptoms making Prepatellar

bursitis, right knee a more likely diagnosis. The ordered lab tests eliminated Prepatellar

bursitis, right knee as the diagnosis.

Primary Diagnosis:

M17.11 - Unilateral Primary Osteoarthritis, right knee: This is a medical condition that is

characterized with the wear and tear of the right knee cartilage (Fathi, 2019). The

development of the condition causes the joints bones to rub excessively against each

without shock-absorbing benefits of the cartilage (Fathi, 2019). The risk factors include

female gender, older age, bone deformities, joint injuries, obesity and repeated stress in

the joints. The condition presents with swelling, pain, loss of flexibility, stiffness, grating

sensation and tenderness of the affected joint (Fathi, 2019). The patient came to the office

and reported these symptoms making unilateral primary osteoarthritis, right knee a more

likely diagnosis. The history, physical exam and ordered lab tests confirmed Unilateral

Primary Osteoarthritis, right knee as the primary diagnosis. Plan/Therapeutics Plan: The objective of the treatment is to relieve the patient’s pain and restore the

patient’s normalcy. Topical analgesia is the first line of treatment for osteoarthritis that

presents with joint pain (Fathi, 2019). The patient’s condition is also managed with non-

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pharmacologic approaches (Fathi, 2019).

The patient was given capsaicin topical to apply on the affect area to help her with the

pain and inflammation. The patient was also given patient education and referred to a

physical therapist to help her with the physical exercises.

Further testing: None.

Medication: Capsaicin topical 0.025% apply to the right knee four times daily.

Education: Patient advised to lose weight to avoid putting weight on the affected knee

(Fathi, 2019). Patient instructed to exercise regularly to strength her joint muscles and

increase her endurance.

Non-medication treatments: Physical therapy.

Return to clinic: Patient to return to the clinic after 3 months for check up.

Referrals: Patient referred to a physical therapy to help her with low-impact exercises. Evaluation of patient encounter

Patient was cooperative with the exam and history taking making my work easy. This

case relied on evidence-based clinical practice in assessing, diagnosis and coming up

with the treatment plan. This case made me realize that it is important to always carry out

a comprehensive history taking, physical exam and lab test to avoid misdiagnosis since

there are conditions like Prepatellar bursitis, right knee that have similar symptoms. References

Burmester, G. R., & Pope, J. E. (2017). Novel treatment strategies in rheumatoid arthritis.

The Lancet, 389(10086), 2338-2348.

Fathi, H. M. (2019). Unilateral versus bilateral primary knee osteoarthritis: Relation to

the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), C-

reactive protein and radiological assessment in Egyptian patients. The Egyptian

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Rheumatologist, 41(4), 271-276.

Ragab, G., Elshahaly, M., & Bardin, T. (2017). Gout: An old disease in new perspective–

A review. Journal of advanced research, 8(5), 495-511.

Sato, M., & Watari, T. (2020). Housemaid’s Knee (Prepatellar Septic Bursitis). Cureus,

12(9).

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