Feb 23, 2024 Make a SOAP Note Not a narrative essay: Assessing Muscoskeletal Pain
Make a SOAP Note Not a narrative essay: Assessing Muscoskeletal Pain
Patient Information:
JR, 15-year-old, Hispanic, Male
S.
CC: dull pain in both knees.
HPI: Patient is 15-year-old Hispanic male that reports dull pain in both knees. On occasion one or both knees click, patient also describes a catching sensation under patella.
Location: Bilateral knees
Onset: A week ago
Character: achy dull burning sensation, catching sensation under patella.
Associated signs and symptoms: swelling on occasion.
Timing: after strenuous physical activity.
Exacerbating/ relieving factors: bending of the knees intensifies pain. Ice to knees, ibuprofen for pain, resting relieves the pain.
Severity: 6/10 pain scale.
Current Medications: Ibuprofen 600mg Q8hrs as needed for pain. No other medications or supplements.
Allergies: No known allergies to medications. No known seasonal allergies. No latex allergies.
PMHx: Patient is up to date on childhood vaccinations. No surgeries. The patient had a knee injury a couple of weeks ago.
Soc Hx: Patient lives with parents, has no siblings, is a freshman in high school. Plays soccer. Denies any alcohol use, denies any nicotine use or smoking, no vaping either. Denies any illicit drug use.
Fam Hx:
Father: Hypertension
Mother: No chronic conditions.
Maternal Grandmother: Hypertension, Asthma
Maternal Grandfather: Congestive heart failure
Paternal Grandfather: Coronary artery disease, Hypertension
Paternal Grandmather: Osteoarthritis, Hyperlipidemia
ROS:
GENERAL: Denies any weight loss or gain, fevers, or chills.
SKIN: No rash but states his right knee is warm to the touch sometimes.
CARDIOVASCULAR: Denies any chest pain, palpitations, or discomforts. No edema noted.
RESPIRATORY: Denies any shortness of breath.
NEUROLOGICAL: Denies any headaches, dizziness.
MUSCULOSKELETAL: Bilateral knee pain, along with some catching of patella. No other muscle or joint pains.
PSYCHIATRIC: Denies any anxiety or depression.
O.
VS: BP 110/60, HR 72, RR 18, T 37.0, HT 5’6”, WT 120lbs
GENERAL: Patient healthy looking, calm, and cooperative. Follows spoken commands. Clear speech, gait steady.
SKIN: Right knee is warm to touch. Left knee cool. No rashes or other abnormalities noted.
CARDIOVASCULAR: S1 and S2 heard no other abnormalities heard. No edema visible in upper or lower extremities. Heartbeat strong and regular.
RESPIRATORY: Lung sounds present in all lobes of lungs.
NEUROLOGICAL: Patient alert and oriented x4. Normal speech, no motor deficits noted. Muscle strength 5/5, sensation intact upper and lower extremities.
MUSCULOSKELETAL: Pain with movement of knees inward, minor swelling noted bilaterally of knees, right knee warm to touch, left cool to touch.
PSYCHIATRIC: Calm and cooperative, no anxiety present.
Diagnostic results: X-ray: can show any type of fractures, bone abnormalities, bone breaks (Cluett, 2022).
CT: If x-ray is negative and issues persist MRI is the next step to assess tendons, ligaments, and muscles.
MRI: If CT is inconclusive and issues persist MRI is the next step to assess tendons, ligaments, and muscles (Clinic, 2023).
A.
Torn meniscus: for this injury we could perform a joint line tenderness test, McMurray’s test, or Ege’s Test. All these tests can be done in clinic however this diagnosis should be confirmed with imaging. Typically, an MRI is needed to diagnose a torn meniscus (Cluett, 2022).
Bakers Cyst: This is an accumulation of fluid under the knee cap. Typically causing swelling in the knee, sometimes some warmth to the touch. No real treatment for this condition, treatment is that of conservative manner such as rest and elevation. NSAID’s along with other pain medications can be used to help with the pain encountered (Starkweather, 2019).
ACL tear: Tear of the anterior cruciate ligament. The tests that can be done with for this are Lachman test, Anterior Drawer test, and the Pivot shift test (Beutler, 2022).
For this patient we would need to know if he has had any previous injuries to his knees. Assess his complete range of motion with both knees. Clarify what intensifies the pain or swelling. Complete all testing needed prior to diagnosing him. This would include X-ray to start off with and then proceed to MRI or CT if needed.
References
Beutler, A. M. (2022, 08 11). Physical Examination of the Knee. Retrieved from UptoDate: http://www.uptodate.com
Cluett, J. (2022, 05 21). Examination of the Knee. Retrieved from VeryWell Health: https://www.verywellhealth.com/examination-of-the-knee-2549602
Starkweather, A. (2019). Assessment and Mangagement of Knee Pain. Topics in Pain Management.
Note: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.
CASE: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
To prepare:
With regard to the case study you were assigned:
· Review this week’s Learning Resources, and consider the insights they provide about the case study.
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· Consider what history would be necessary to collect from the patient in the case study you were assigned.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):
1. A description of the health history you would need to collect from the patient in the case study to which you were assigned.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
4. Include how the patient X-ray helped you to refine the differential diagnosis
REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.
Resources:
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)
o Chapter 21, “Musculoskeletal System” (pp. 501-543)
This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 22, “Limb Pain” (pp. 356-374)
This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.
o Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)
The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.
· Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”; p. 26)
o Chapter 4, “Pediatric Preventative Care Visits” (“Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam”; pp. 78–79)
Note: Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Musculoskeletal system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Musculoskeletal System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., & …Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.
Retrieved from the Walden Library databases.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
· Vismara, L., Menegoni, F., Zaina, F., Galli, M., Negrini, S., & Capodaglio, P. (2010). Effect of obesity and low back pain on spinal mobility: A cross sectional study in women. Journal of Neuroengineering & Rehabilitation, 7(1), 71–83.
Retrieved from the Walden Library databases.
In this study, the authors explore the effect of obesity and chronic low back pain on spinal mobility. The authors use range of motion as a metric of spinal mobility.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on skeletal trauma in musculoskeletal radiology.
Media
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.
Optional Resources
· LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.
o Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)
In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities
Patient Information: T.J., 15 years old, African American Male
CC “Both Knees hurt, especially when I walk upstairs. Sometimes I hear clicking sound along with this strange catching sensation under my knee”
HPI:
TJ is 15 -year-old African American male with bilateral patellar pain, dull in nature and localized around anterior knee area. The pain started 3 days ago and was associated with walking up and downstairs, running, and squatting. The knee pain frequently comes with a “clicking” noise and catching sensation under patella. Severity described as 7/10 .
Reports that Aleve makes it tolerable, but not completely better. Takes 1 caplet 220 mg q 8-12 hours. Exacerbating factors reported by the client are walking, jumping, and squatting.
Current Medications: Aleve 220 mg every 8-12 as needed for pain . No RX medications, no other over the counter medications.
Allergies:
No known allergies. Denies food , environmental and latex allergies.
PMHx:
Up to date on all his immunizations, last COVID booster in April 2022, last flu vaccine December 2021.
Fractured right tibia three years ago while playing football, Denies history of arthritis, rheumatic fever, or Lyme disease. Denies any prior surgeries and /or hospitalizations.
SocHx: TJ identifies himself as “heterosexual”, but he is not sexually active. He lives with his parents. Denies any tobacco , alcohol, or illicit drug use. TJ is a high school student at Thomas Jefferson High school. He enjoys playing sports , football is his favorite sport. He is a wide receiver on the school football team. TJ runs in the morning and goes to the gym during the afternoons. TJ wears his seatbelt whenever riding in a motor vehicle , reports getting 8-10 hours of sleep a night. He likes spending time with his friends and going movies.
Fam Hx: T.J parents are both still living. Dad 49 years old has history of HTN, Peptic ulcers, and gout . Mom 51-year-old has CHF and HTN. His younger brother does not have any significant health history.
ROS:
GENERAL: TJ does not have weight loss, denies fever, chills, weakness or fatigue.
HEENT: Eyes: Denies blurred or loss vision. Denies double vision. No yellowsclerae noted.
Ears, Nose, Throat: Reports no hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum production.
GASTROINTESTINAL: Denies intestinal discomfort, nausea, vomiting or diarrhea. Reports no abdominal pain or blood.
GENITOURINARY: Reports No Burning on urination.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control.
MUSCULOSKELETAL: positive for bilateral patellar pain , tenderness, and slight edema around Right and left knee.
HEMATOLOGIC: reports no anemia, bleeding or bruising.
LYMPHATICS: denies enlarged nodes and history of splenectomy.
PSYCHIATRIC: reports no depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Temp 98.6 F, Pulse 60, respirations 20and non labored. SPO2 100% on room air, BP 125/78mmhg. Weight 136 lbs, H5’8’’
Diagnostic tests:
CT scan, MRI, and Xray.
Blood Tests:
CBC (inflammation and infection screening), Erythrocyte Sedimentation Rate(Inflammation screening) , Uric Acid (rule out gout), Rheumatoid Factor (rheumatoid factor)
Differential Diagnoses
Patellofemoral Pain Syndrome .The main cardinal feature of pain around anterior knee that worsens with descending stairs , squatting , and bending knee during weight bearing activities(Gaitonde, 2019).
Patellar dislocation or Fracture . The main feature of this diagnosis is that occurs mostly in adults younger than 20 years old and accounts for more than 93% of the cases. It is usually the result of trauma or twisting tibia during physical activities(Ball, 2019), (Thijie,2019).
Bursitis .It is an inflammation of the bursa that results in tenderness of the knee and knee pain. (Daines et al., 2019).
Chondromalacia Patella(Runner’s knee) is a disease of the hyaline cartilage coating of the articular surfaces of the bone (Habusta et aal, 2019).
Osgood-Schlatter Disease (OSD) – A condition in which the patellar ligament insertion on the tibial tuberosity ends up inflamed (Vaishya et al., 2018).
References
Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral Pain Syndrome. American family
physician, 99(2), 88–94.
https://pubmed.ncbi.nlm.nih.gov/30633480/
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019)
Seidel’s guide to physical examination: An interprofessional approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
ten Thije, J. H., &Frima, A. J. (2019). Patellar dislocation and osteochondral fractures. The Netherlands journal of surgery, 38(5), 150–154.
https://pubmed.ncbi.nlm.nih.gov/3774187/
Dains, J. E., Baumann, L. C., &Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Habusta, S., Coffey. R, Ponnarasu S, et al.(2022) Chondromalacia Patella.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/
Vaishya R, Azizi A, Agarwal A, et al.(2018) Apophysitis of the Tibial Tuberosity
doi:10.7759/cureus.780
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