SOAP NOTE: From Contingency Plan: Aquifer Family Medicine 11: 74-Year-Old Female with Knee Pain | NSG6020_W6_A4_Carpenter (answered)

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SOAP NOTE: From Contingency Plan: Aquifer Family Medicine 11: 74-Year-Old Female with Knee Pain Name: Ms. Roman Date: 6/18/2020 Time: 0900 Age: 74 Sex: Female SUBJECTIVE CC: "I've been havin... g some pain in my right knee. It's really been bothering me. It feels achy all over. I've had knee pain off and on for months, but it has become more constant for the last several weeks. When the pain didn't seem to be going away, I decided to come see the doctor." HPI: The patient is a 74-year-old Caucasian female who presents to the doctor’s office today with the chief complaint of right knee pain. She has reports that the knee pain has been intermittent for months, but has become more constant over the past several weeks. She has had no injuries, and no past surgeries, but does report that she “hits her knee” while gardening sometimes. She reports the pain as a 6 on a scale of 0-10, and reports it as a “grinding” pain. She has some decreased range of motion and crepitus with moving the right knee. The pain gets better with rest, and worse throughout the day with activity. Bengay also helps with the knee pain, but she reports she has not tried to take any oral medications. Medications: (list with reason for med ) Multivitamin Extra-strength Tylenol (PRN for pain) Tums (PRN for heartburn) PMH GERD (patient controls with PRN Tums) Alcohol Use Disorder Allergies: NKDA Medication Intolerances: CONTINUED [Show More]

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