soap note 2

SOAP

Demographics

(L.S.) is a 72-year-old African American black female.

Chief Complaint (Reason for seeking health care)

“My knee has been hurting and bothering me more than usual, especially when I walk or try to go up the stairs in my sister’s house.”

History of Present Illness (HPI)

According to the patient, he has been experiencing increased pain in his knees over the past 6 months and the right knee is more affected now. It is a slow, unclear pain, usually registering 6/10 on the scale and rising to 8/10 if I become more active. The problem is made worse by continuing to move for hours on end by walking, standing, or climbing stairs. L.S. found that resting and taking ibuprofen helps a little. No reports of locks or instability could be found. She insists that she hasn’t been hurt or had a trauma in the recent past. Because of the pain, she has difficulty gardening, something she likes to do.

Allergies

L.S. reports having an allergy to ciprofloxacin, but no environmental, herbal, latex, and/or food allergies reported.

Review of Systems (ROS)

General: Denies recent gain or loss in weight, chills, or nighttime sweats. Reports occasional feelings of weakness.

HEENT: Denies headaches or changes in her vision.

Neck: Denies stiffness or swelling.

Lungs: Denies shortness of breath or cough.

Cardio: Denies chest pain or palpitations.

Breast: Denies masses or nipple discharge.

GI: Denies nausea, vomiting, or bowel changes.

M/F genital: Denies vaginal discharge, itching, or pain.

GU: Denies urinary incontinence or dysuria.

Neuro: Denies dizziness or tingling. Denies balance issues.

Musculo: Admits bilateral knee pain, worse on right. No joint swelling in other areas.

Activity: Admits decreased mobility due to knee pain; uses rail support when climbing stairs.

Psychosocial: Admits that she lives alone but has daily check-ins from her daughter. Slightly withdrawn socially due to mobility issues.

Derm: Denies rashes or open wounds.

Nutrition: Balanced diet; denies any alterations in her cravings or appetite.

Sleep/Rest: Admits difficulty falling asleep due to knee discomfort.

LMP: Patient is post-menopausal.

STI Hx: Non-contributory

Vital Signs

BP: 136/71 mmHg maintained while in a chair.

HR: 68 bpm

RR: 16 breaths/min

98.4°F oral

SpO2: 99% on room air

168 lbs

5’4”

BMI: 28.8 (Overweight)

Pain Score: 6/10 (rest); 8/10 (activity)

Labs

No recent labs at this time.

Medications

Ibuprofen 400 mg PO tab TID PRN for pain (Hannon et al., 2023)

Vitamin D 1000 IU PO tab daily

Calcium carbonate 600 mg PO tab BID

Lisinopril 10 mg tab PO daily

Past Medical History

Hypertension (diagnosed at age 52, not current, controlled with medication)

Hyperlipidemia (diagnosed at age 45, resolved and not active)

Osteoarthritis (diagnosed 5 years ago, current)

Vitamin D deficiency (diagnosed 9 years ago, current)

Past Surgical History

Right cataract removal (age 68, to improve vision)

Family History

Mother: osteoarthritis, deceased at 84 (MI) Father: Type 2 diabetes, deceased at 78 (stroke) Sister: 75 y/o, living, hypertension and obesity.

Sister: 70 y/o, living, hypertension, depression

Social History

Widowed. Currently not working, retired librarian. Lives in a one-story home with support bars in the bathroom, no stairs within the residence, no rugs, appropriate lighting. Non-smoker. No alcohol or recreational drug use. Has a close relationship with family and neighbors. Not sexually active, heterosexual.

Health Maintenance/ Screenings

Mammogram: performed last year in September, normal result

Colonoscopy: 2022, benign polyps

Bone density scan: 2 years ago: osteopenia

Auditory exam: WNL

Vaccinations: up to date, received shingles vaccine and annual flu shot

Physical Examination

General: Alert, cooperative, oriented, well appearing

HEENT: PERRLA, oropharynx clear

Neck: Supple, no lymph node tenderness or inflammation, symmetric

Lungs: Clear to auscultation bilaterally, no wheezing rales or rhonchi

Cardio: Regular rate and rhythm, no present murmur

Breast: No masses or discharge

GI: Abdomen soft, no tenderness present, bowel sounds normoactive

M/F genital: Deferred

GU: Unremarkable

Neuro: Alert and oriented x3, all cranial nerves intact

Musculo: Crepitus in both knees, mild tenderness medially, decreased flexion in right knee. No effusion or redness.

Activity: Antalgic gait noted, uses cane for long distances

Psychosocial: Slightly discouraged due to mobility limitations

Derm: Skin intact, no lesions or ulcers

Diagnosis

Osteoarthritis of bilateral knees (M17.0)

Differential Diagnosis

Rheumatoid arthritis

Meniscal injury

Gout

ICD 10 Coding

M17.0 – Bilateral primary osteoarthritis of knee

Pharmacologic treatment plan

Continue Ibuprofen 400 mg PO tab TID PRN for pain, with food.

Add topical NSAID: Diclofenac 1% gel, apply to knees QID prn for knee pain

Diagnostic/Lab Testing

X-rays of both knees to compare and assess each knee individually and analyze the joint space of the affected knee and rule out acute changes.

Blood work: CBC, ESR, CRP, RF to rule out inflammatory arthritis

Education

Strategies to manage symptoms:

Educated patient on joint protection, using assistive devices correctly, and importance of regular movement to maintain flexibility, and possibly avoid the knee for surgical intervention (Hannon et al., 2023). Discussed potential side effects of NSAIDs (GI irritation, kidney effects).

Self-management methods:

Recommended alternating hot/cold compresses and gentle knee exercises (Gibbs et al., 2023). Incorporate simple and realistic home exercises. Reinforce adequate fluid intake and importance of abstaining from substance abuse as this can influence bone density.

Anticipatory Guidance

Primary prevention:

Strive to maintain a healthy weight as this can aid in lessening the weight on the body’s joints. Prioritize proper footwear that can provide support to the foot, and cushioning. Encourage low-impact exercises (neighborhood walks, swimming, biking).

Secondary prevention:

Prioritize the use of knee braces to provide support and ensure proper alignment. Evaluate current medication use and possible side effects that can negatively impact bone density. Refer to physical therapy for strengthening. Maintain healthy weight to reduce joint strain. Monitor for new or worsening joint symptoms.

Follow up plan

Follow up in 4 weeks for reassessment.

Call sooner if pain worsens or new symptoms arise.

Review imaging and labs when available.

EA#: 12341234 STU Clinic LIC# 12344321

Tel: (123) 123-4321 FAX: (123) 123-123123

Patient Name: (Initials)L.S. Age __72

Date: 05/31/2025

RX _Diclofenac 1% gel

SIG: Apply to both knees QID prn for knee pain

Dispense: _100g tube__ Refill: 1

No Substitution

Signature: __________________________________________________________