Bilateral Knee osteoarthritis Soap note (complete) SOAP Note: Patient: Mrs. F Age: 75 Gender: F Marital Status: Widow Race: Hispanic

Document Content and Description Below

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 osteoarthriti... s 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. [Show More]

Last updated: 1 year ago

Preview 1 out of 3 pages