25 Mar Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable histo
Below is the attached copies of the rubric, school sample and the sample of the soapnote am writing
70 year old female with pain and inflammation in my right knee
TOPIC UNILATERAL PRIMARY OSTEOATHRITIS RIGHT KNEE
please do not add the evaluation of the patient encounter
SOAP Note Week Two
United States University
FNP592: Common Illnesses Across the Lifespan
Dr. Theresa Gress
October 1, 2020
SOAP Note Week Three
ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.
S:
CC: “Cough, runny nose, and sore throat x 7 days”
HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian
PMH:
Allergies: No known drug allergies. Strawberries (rash), seasonal allergies Childhood: Asthma until high school, chickenpox at age 2
Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)
Medications: None
Vaccinations: received childhood vaccines, Last flu shot given Oct 2019.
Denies psychiatric history.
Social History:
Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink
2 months ago, Engaged, works in IT, Hobbies include archery.
Family History:
Mother died age 60-Diabetes II Sister 42yo living -HTN Maternal Grandma died age 67- Dementia
ROS:
General: No weight change, weakness, fatigue, fevers..
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORRHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam was 4 months ago.
C/V: Denies chest pain, palpitations. Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain Neuro: No headache, dizziness, focal numbness/weakness, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness.
O:
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8
Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.
HEENT: Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat. Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema but no cobblestone appearance. Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline. Neuro: Alert and oriented x 4. Cardio: RRR. Crisp S1 S2 without clicks or murmurs.
Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.
(***notice not all systems are in the PE when doing a focused exam on a problem)
A:
Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS
1. Viral pharyngitis – most likely as evidenced by sore throat, cough, no fever (Stead, 2019). (←←←←←that is a practice treatment guideline)
2. Strep Throat – not as likely; no fever and 7 days duration, age not as consistent with this dx
3. Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.
DX: Viral pharyngitis
P:
In house throat swab for rapid strep – negative.
Continue to rest and drink lots of fluids (Cash & Glass, 2017; Stead, 2019).
Continue OTC Dayquil/Nyquil PRN per directions on the box – Safe dosing discussed, sedation may occur with Nyquil, avoid driving or operating heavy machinery after taking.
Encourage tea with honey and lemon to help with cough and sore throat.
Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.
Do not drink alcohol while taking these medications.
Cover mouth when coughing, do not drink after other people (Cash & Glass, 2017).
Return to office in 3-4 days if symptoms do not improve, worsen, or get better and then again get worse (Cash & Glass, 2017). Call 911 or go to ER for trouble breathing or any other emergent concern (Stead, 2019).
References:
Cash, J. & Glass, C. (2017). Family practice guidelines. New York, NY. Springer.
Stead, W. (2019). Symptomatic treatment of acute pharyngitis in adults. In L. Kunnis
(Ed.). UpToDate Retrieved February 12, 2020 from:
https://www.uptodate.com/contents/symptomatic-treatment-of-acute-pharyngitis-
in-adults
,
1
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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