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SOAP Note:
Patient: Mrs. F Age: 75 Gender: F Marital Status: Widow Race: Hispanic
SUBJECTIVE:
CC: “Both of my knees hurt a lot” HPI: The patient presents today for follow up of osteoarthritis of the bilateral knees. She reports that the pain in the knees has been increasing in severity for the past 2 years. She states the pain ranges in severity from 3 to 10 (out of 10), but since Monday this week the pain is worse rating of 7/10 in the right knee and 5/10 in the left knee. Patient also reports that she has notice that the right knee is inflamed. Pain is partially alleviated by rest and ibuprofen. Patient admits to stiffness (worse in morning or with inactivity) that resolves in 5 - 10 minutes with movement and reduced ROM due to pain/stiffness. PMH : Allergies: Iodine Childhood Illness: Recurrent tonsillitis Adulthood illness: Osteoarthritis and Cataracts Surgical History: Hysterectomy Medication List: Ibuprofen 400 mg every 6 hours FH: Mother – Lung cancer, heart disease, hypertension, diabetes. Father – Diabetes. bother – Alcoholism. SH: Patient has history of smoking for 27 years. Does not drink alcohol. She is retired, currently living with a daughter. Patient does not have a regular exercise routine. Patient states that she tries to eat healthy food but she is unable to lose weight because of her incapacity of do exercises due to the pain ROS Constitutionals : Denies fevers, chills, fatigue, malaise, and headache. Head/Eyes : Denies ear pain, fullness, popping, loss of hearing, or drainage. Denies blurry vision, eye pain, itching, or drainage. ENMT : Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore throat, loss of taste, difficulty swallowing, and bleeding gums. Denies tooth pain, gum pain, and difficulty chewing. Cardiovascular : Denies chest pain, palpitations, syncope, and shortness of breath. Denies palpitations, orthopnea, and syncope. Respiratory : Denies cough and sputum production. Gastrointestinal : Denies nausea, vomiting, constipation, melena, indigestion, reflux, dysphagia, diarrhea, and loss of appetite. Genitourinary : Bilateral lower quadrant abdominal pain/pressure. Complains of dysuria, polyuria, burning, frequency, and incomplete bladder emptying, without hematuria, offensive odor of urine, or back/flank pain. Musculoskeletal : Patient reports bilateral knee pain, right knee pain 7/10 and left knee pain 5/10. She also reports inflamed right knee articulation. Reports stiffness of muscle/joints in the morning with some, limitations to ROM. Denies muscle cramps, deformities and weakness. Integumentary : Denies rashes, new moles, itching, acne, or other skin changes. Neurological : Denies memory loss, imbalance, weakness, paralysis, numbness, tingling, tremors, disorientation, speech disorders and involuntary movements.
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Psychiatric : Denies mood changes, nervousness, depression, therapy/counseling, psychiatry disorders and hallucinations Endocrine : Denies Thyroid disorders, heat/cold intolerance, excessive sweating.
OBJECTIVE DATA:
VS : BP:125/83, HR: 95, RR: 18, Temp: 98.3, weight: 199lb, height: 5’1, BMI: 37. PHYSICAL EXAM: General: Mrs. F is alert and awake and responding appropriately. Afebrile. Skin warm and dry. Head/Eyes : Head is normocephalic, atraumatic, and symmetrical. Sclera and conjunctiva clear, no discharge, PERRLA. ENMT : Neck midline, trachea midline, without lymphadenopathy. Bilateral external ear size, shape, and skin tone normal. Both ears had three piercings each, no masses, or tragal tenderness. External canal inspection reveals patent canals, without odor, discharge or foreign bodies bilaterally. Bilateral internal ear inspection reveals a pink canal with a tympanic membrane that is pearly gray, concave, with light reflex and visible bony landmarks, without ear cerumen. Nares patent bilaterally, nasal septum midline, turbinates pink and moist, without nasal discharge. Mucus membranes pink, moist without lesions, hard and soft palate intact. Some teeth present, no teeth missing, 1 broken molars to the right upper and lower dentin, evidence of active decay, gum redness, no puss or bleeding visualized. Pharynx pink, tonsils 1+ without exudates or pitting, uvula midline, tongue midline, sensitive gag response. Maxillary and frontal sinuses non-tender tender to palpation. Cardiovascular : Examined seated and supine. No abnormal pulsations, lifts or heaves notes. No thrills; PMI in 5th^ ICS-ML. S1 louder at apex, S2 louder at base. RRR with no murmurs, clicks or gallops heard. Respiratory : Lungs clear to auscultation, without crackles, wheezes or rhonchi. Normal S1 & S2 without any splits, skips, rubs, gallops, or murmurs. No costovertebral angle or back tenderness to palpation. Gastrointestinal : Abdomen is flat and symmetrical. No scars, dilated veins, rashes, lesions, peristalsis or pulsations visible. Umbilicus midline, without bulges. Bilateral abdominal stretch marks from childbirth. Active bowel sounds in all four quadrants, no aortic, renal, iliac, or femoral bruits auscultated, no friction rubs heard over the liver or spleen. No palpable masses or hepatosplenomegaly. Spleen and kidneys not felt. Aortic pulsations slightly palpable. Genitourinary : Abdomen soft, non-tender to light and deep palpation. Musculoskeletal : Gait with some instability due to pain, Muscle strength 5/5 to all groups. Neck, shoulder, elbows, wrists, hands and feet with full ROM to all planes and w/o deformities noted. Spine with full ROM and curvature WNL; no paravertebral tenderness. Knees: Right knee shows neurovascular status is normal. Crepitance is 3, and active range of motion is 5 to 110 degrees and passive range of motion is 4 to 120 degrees. There is a flexion contracture at 10 degrees. Effusion is 1+ and ligaments are normal. The meniscal signs are absent. Left knee shows neurovascular status is normal. Crepitance is 2, and range of motion is 5 to 120 degrees. Effusion is 0 and ligaments are normal. The meniscal signs are absent. Integumentary : Overall fair without significant lesions noted; turgor good, warm ad moist. Hair distribution, texture and quantity overall unremarkable. Nail bed pink with good capillary refill. Neurological : Alert, oriented in space, time and person. No mental status noticed, Cranial Nerves 2 - 12 intact, DTR 2+ to upper and lower extremities; Babinski negative; Sensory intact to proprioception, sharp-dull discrimination, vibration and stereognosis. No motor deficit noticed. Cerebellar function intact to nose pointing and rapid alternating movements. Romberg negative Psychiatric : No
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