Soap note

IMMUNIZATIONS: Updated according to the patient age.

PREVENTIVE CARE: Blood pressure screening currently normal, Cholesterol screening under normal limits with diet. Fecal occult blood negative. Flexible sigmoidoscopy done 5 years ago negative for colorectal cancer or polyps. Colonoscopy done 10 years ago normal. Breast self-exam no palpable mass. Mammogram 1 year ago within normal limits for her age. Hemoglobin A1c level measures for the past 6 months normal. DEXA scan demonstrated normal results negative for osteopenia and osteoporosis. P.A.P Smear negative for HPV and cervical cancer last year. Dental checkup every 6 months, Hearing screening test normal, Thyroid screening last year normal

SURGICAL HISTORY: Cholecystectomy 7years ago. Right Knee arthroscopy with partial medial and lateral meniscectomy 5 years ago. Breast lump excision 20years ago. Appendectomy 30 years ago.

FAMILY HISTORY: Father- alive, 85 years old.

Mother-deceased, 75 years old, Diabetes Mellitus, Heart attack

Daughter-alive, 38 years old, healthy.

Son: alive, 32 years old, healthy

She was not adopted.

SOCIAL HISTORY: She is not a smoker, occasional alcoholic beverage consumption on social celebrations. She completed 12 years at school. She has never been physically, sexually or emotionally abused. Married 40 years ago (husband is alive). She is currently a house keeper at Palm Beach Garden. She were raised in Colombia. Home environment when young without parental divorce or separation, socioeconomic middle class, hobbies gym , she has not limitations to perform her activities of daily living, she has a satisfactory sex life, she is catholic. She eats healthy,

SEXUAL ORIENTATION: Straight

NUTRITION HISTORY: Diets low in sugar, carbohydrates and sodium due to her health conditions. She eats a lot of vegetables.

SUBJECTIVE DATA:

Chief Complaint : “Left Knee pain medial and lateral aspect for the last 6 months”.

Symptom analysis/History Present Illness:

This is a patient of 64 years old female who complaining of Left knee pain more intense over the medial aspect. The level of pain in scale from 0 to 10, the patient describes it as 6. Patient states mechanical symptoms like popping and cracking sensation over the patellofemoral joint and medial compartment of the knee. The pain increases significant going up and down stairs. Patient denies neurological symptoms like numbness or tingling sensation. She is also complaining of pain over the popliteal zone. Patient states that she has these symptoms for the last 6 months however it is getting worse lately. Patient does not show altered nutritional status and water balance. There is no alteration in your self-care to dress or undress but she states some limitations bending forward. Patient does not present difficulties for learning or knowledge deficit. The patient currently has symptoms compatible with knee osteoarthritis.

REVIEW OF SYSTEMS (ROS):

CONSTITUTIONAL: Patient states pain over right and left knee but the left knee is worse. Denies fever or chills. Denies weakness or weight loss.

NEUROLOGIC: Denies significant headache, seizures, tremors, slurred speech or difficulty moving an arm or leg. Denies tingling and numbness sensation. She denies dizziness. No focal neurological deficits. CN II-XII grossly intact.

HEENT: HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. No scleral icterus EAR: Denies pain in the ears. NOSE: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Moist mucous membranes. No cervical lymphadenopathy. EARS: Patient denies pain, discharge, tinnitus, vertigo.

RESPIRATORY: Patient denies shortness of breath. She denies cough or hemoptysis. Lungs auscultation with normal sounds are heard bilaterally, no accessory muscle use. She denies cough, sputum, hemoptysis, night sweats.

CARDIOVASCULAR: She denies chest pain or tachycardia, no orthopnea or paroxysmal nocturnal, edema, she denies hypertension, previous myocardial infarction, claudication, thromboses, thrombophlebitis, Regular rate and rhythm. No murmur. No JVD,

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. Abdomen soft, non-tender and non-distended. No palpable masses. Denies constipation, intolerance for any class of food, dysphagia, heartburn, hematemesis, denies any change in stool color or contents, hemorrhoids, history of ulcer,

GENITOURINARY: Patient denies hematuria, polyuria and dysuria. Denies difficulty starting/stopping stream. Denies flank or suprapubic pain. She denies stress incontinence, STIs.

MUSCULOSKELETAL: Pain bilateral knees. Right knee pain and stiffness greater than left knee pain. Denies falls. She States hearing popping, clicking, snapping and cracking sound right knee. Denies myalgia. Denies lower back and hip problems like pain, restriction of motion, swelling, redness, heat or bony deformity.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Denies excessive sweating or abnormal nail or hair growth.

PSYCHIATRIC: Denies depression, mood changes, difficulty concentration, anxiety, agitation, suicidal thoughts, irritability, sleep disturbances

MENSES: Age at menarche 12 year old, age at menopause 50 years old, denies bleeding, itching, denies pain during intercourse.

Objective Data:

VITAL SIGNS: Temperature: 98.7 °F, Pulse: 79/min, BP: 120/75 mm hg, RR 26/min, PO2-98% on room air, Ht- 5’2”, Wt 150 lb, BMI 27.4. Report pain 6/10.

GENERAL APPREARANCE: The patient is alert and oriented x 3. Acute distress is not noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Libs non-remarkable and appropriate for race.

NECK: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: Normal respiratory pattern. There is not observed used of accessory muscles. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents bilaterally.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: There is pain to palpation over the right knee medial and lateral compartments. Cracking sensation over the patello-femoral joint bilateral knees. Active and passive ROM limited due to the pain bilateral knees (Right knee worse compared with left knee). There is Knee effusion right knee. Varus deformity right knee. Bilateral hips within normal limits, no stiffness, no pain during range of motion. Lower back active and passive ROM without pain or limitations. Bilateral shoulder within normal limits.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis

The patient has clear symptoms of Left knee osteoarthritis. (ICD-10 M17-11). Osteoarthritis is a bone pathology “wear and tear” common in elderly patients. It’s within the 10 main cause of disability. The most common cause is the age. However, another factors could make this worse: overweight, heredity, gender ( women more than men), athletics, metabolic disorders, rheumatoid arthritis. The diagnosis is done in the first appointment with the physical exam complemented with X-rays and MRI. The main problem of this condition is the limitation of the range of motion of the joints and pain affecting the quality of life. The main cause is the destruction of the joint cartilage called “Natural Cushioning” with exposure of subchondral bone where are the nociceptive receptors and the joints rub the bones together closely. There are different levels of osteoarthritis according to cartilage damage, where the worse is Level IV called “End Stage OA” where the only option of treatment is the joint replacement. (Altamura S.A., 2020).

The pathogenesis of osteoarthritis has different factors: cartilage damage, synovial inflammation, sclerosis over the subchondral bone, ligament and meniscus problems. The osteoarthritis progression involved different inflammatory mediators and the advance of the cartilage damage can not be stopped because the cartilage is an avascular tissue. The treatment depends on the level of the cartilage compromise. In the early levels of OA nonpharmacologic treatment is the best option like weight loss, braces, physical therapy and diet changes. When this treatment fail, pharmacologic treatment has to be considered oral and topical NSAIDs are used. When nonpharmacologic and pharmacologic treatment fail the next step is the surgical procedures such as arthroscopy, osteotomy or total or partial joint replacement. All different treatments are aimed at improving the quality of life of the patient (Kim M., 2020).

Several scientific studies show that 27 million people in the U.S have knee osteoarthritis and 45% of women older of 64 years have symptoms of knee osteoarthritis with radiological changes as subchondral sclerosis and joint space narrowing and have more functional limitations compared with the men. The chronicity of the osteoarthritis could develop emotional problems and sleep disturbances. That is why prevention, diagnosis and treatment timely is important. (Asgaonkar, 2020)

DIFFERENTIAL DIAGNOSIS:

· Anterior knee pain (ICD10 M25.569). The diagnosis of knee pathology is very varied and difficult to specify. There are different criteria to make the diagnosis of anterior knee pain which is related to the patellofemoral joint most of the time. It is therefore most commonly a diagnosis that is made once other pathologies have been excluded. (Leibbrandt, 2017)

PLAN:

Labs and Diagnostic Test to be ordered:

· Complete blood count (CBC)

· X-Ray of right and left knee AP and lateral sunrise view in order to evaluate the joint space, osteophyte formation, bone sclerosis, deformity.

· MRI right knee will be ordered for deeper evaluation of the soft tissue as meniscus, ligaments and tendons.

Pharmacological treatment:

· Ibuprofen tab.200mg. 1 tab TID PO with full stomach.

· Glucosamine HCL with MSM: Tab. 1500mg: 2 Tabs. PO qd

· Tylenol #3 tab. 1 tab PO qid.

Non-Pharmacologic treatment:

A cortisone injection was given to the patient to improve the pain. The cortisone injection is indicated to reduce the inflammation of the synovium.

Non-pharmacologic treatment involves a dietician and efficient communication with primary care physician and education programs to improve overweight risk factors.

· Weight loss. Keep BMI no higher than 25.

· Healthy diet (DASH dietary pattern): Staples like cereals (wheat, barley, rye, maize or rice) or starchy tubers or roots (potato, yam, taro or cassava). Legumes (lentils and beans). Fruit and vegetables. Food from animal sources (meat, fish, eggs and milk). Limit intake of sugar. Eat less fat. People with diets rich in vegetables and fruit have a significantly lower risk of obesity, heart disease, stroke, diabetes 

· Enhanced intake of dietary potassium and magnesium in order to improve muscle contraction and strength.

· Physical activity: >3h/wk with regular walking regimens or gym. Or 30 mins/day aerobics exercises.

· Physical therapy improvement range of motion and pain over her right knee with gait training.

· Lifestyle improvement strategies: It is extremely important that the patient recognize the risk factors of overweight diseases as joint osteoarthritis because with his knowledge and the taking of preventive measures she will be able to control her weight and reduce pain over weight bearing joints and avoid the serious consequences.

Education:

House education is the implementation of the plan that will be carried out at home, subject to flexibility depending on the evolution of her knee pain, in order to achieve the objectives set at the beginning of the nursing process. Its evaluation will be systematic and continuous, thus guaranteeing a better quality in the care of our osteoarthritis patient.

The patient will be able to understand her illness and how to avoid getting worse of her arthritis possible recurrences of knee pain. The patient will learn to deal with the pain generated by her knee osteoarthritis. Education in the prevention and promotion of health is a great tool in the early detection of osteoarthritis, for its timely treatment and reduction of complications (Joint replacement) thus avoiding greater severity of the condition and worse prognosis.

We must give the patient the necessary and sufficient time to express their anxiety and concerns about this problem which could be very limited to conducting her activities of daily living, resolve her doubts and provide emotional and spiritual support, as well as information and education on important aspects in the understanding of her pathology, treatment, prognosis and resources available for the restoration of her health. Comprehensive care should be given that takes into account the different deficiencies and needs of the patient, to facilitate her process of acceptance of the disease and a prompt disposition for responsibility in her self-care.

Instruction about medication intake compliance is really important. The nurse practitioner has a great responsibility and opportunity to do much good to the people in his care, being able to contribute to the restoration of his integral health and biopsychosocial and spiritual well-being.

Follow-ups/Referrals:

· Follow up appointment 4 weeks. This patient is a candidate for hyaluronic acid injections and Platelet-Rich Plasma therefore we will begin treatment with viscosupplementation injections at that time first. I did explain clearly to the patient if this treatment fails we will start with Platelet-Rich Plasma. Patient agrees with our treatment plan. No referrals needed at this time

References: