SOAP NOTE 2

SOAP NOTE 2

Soap Note

This is an acronym for a method used by healthcare providers for documentation of patient’s information on patient’s charts. A patient’s medical record is an essential part of clinical practice, and this document illustrates how a patient’s report can be written in using the SOAP note format.

Patients Information

Name: P. K

AGE: 15 years

Sex: Male

Race: African American

SUBJECTIVE DATA

Chief Complaint: The patient reports dull pain in both of his knees. At times one or both knees click and he describes to be having a catching sensation under the patella.

HPI: A 15-year old male.

Location: Both knees

Onset: 2 weeks ago

Character: Click and experiences a catching sensation on both knees

Associated signs and symptoms:

Timing: Sitting for long and walking upstairs

Exacerbating/ relieving factor: Squatting, walking upstairs.

Severity: The pain is 8/10 especially at night.

Current Medication: Asprin for the pain

Allergies: None

Patient’s Medical History:

Social History: The patient is a student who lives with his parents and his siblings in a four bedroomed apartment. He is on the football team and likes ridding bicycle after school and goes to church every Sunday.

Family history: The patient’s father arthritis and the mother have diabetes. His grandparents both died in a car crash a few years back.

REVIEW OF SYMPTOMS

GENERAL: He has lost weight due to server training schedule in the team, has no fever, chills or fatigue.

HEENT: No visual loss or blurred vision and no hearing loss, nose congestion or a sore throat.

CARDIOVASCULAR: The patient has no chest pain, chest discomfort no edema or palpitation.

RESPIRATORY: He has no shortness of breath or coughing.

GI: Has no nausea, diarrhea or any abdominal pain.

GU: He does not experience any burning during urination.

NEUROLOGICAL: He has no tingling in his extremities, dizziness, ataxia or headaches.

MUSCULOSKELETAL: Cracking sound on the knee and the pain gets worse during activities like squatting or jumping. The pain seems to get worse mostly at night.

HEMATOLOGIC: He has no history of anemia, bruising or bleeding.

LYMPHATICS: Lymph nodes are not enlarged, and the patient does not have a history of splenectomy.

PSYCHIATRIC: Denies being anxious, any suicidal or depressive thoughts.

ENDOCRINE: He does not have any sweat, heat or cold intolerance.

ALLERGIES: None

OBJECTIVE DATA

Physical Exam

General: weight 126 lbs, height 72.5 inches B.P is123/65mmHg Heart rate is 78.

HEENT: has good vision, no sore throat congestion or running nose.

Cardiovascular: He has no heart murmurs.

Musculoskeletal: the kneecap is tender; and also is slightly bent. Tibial tubercle is tender on the application of pressure. The x-ray indicates that the patella is clearly out of the alignment within the groove of the femur.

ASSESSMENT

Osgood-Schlatter disease. Causes knee pain mostly in adolescents and which is an inflammation at the area slightly below the knee where a tendon from the patella attaches to the tibia (Conchie et al., 2016). Mostly occurs due to physical stress on muscles and bones. The patient is a foot player who has been training vigorously for the past few months.

Meniscus tear of the knee. The meniscus is cartilage that cushions between the femur and tibia; it can be damaged during activities such as training or a hard tackle during football practice which could have been the case with the patient (Sihvonen et al., 2016).

Runner’s knee is another condition that the patient might be having. This condition is mostly brought by running that puts a strain on the knee causing to start paining (Bebeley, Yi-Gang, & Yang, 2016).

Anterior circulate ligament tear another possible diagnosis for the patient; it is an injury to the ligament in the knee that keeps the shinbone from sliding forward when one moves (Quinn et al., 2016). It is a common injury among teenagers in sports, and the patient is one of them.

Posterior cruciate ligament injury is another condition that the patient might have. Ligaments are strong bands of tissue that connect bone to bone (Zeng et al., 2016). This ligament is the strongest at the knee joint, and it runs back from knee joint from the femur to the tibia. It aids in stabilizing the knee joint at the back, and an injury can occur during a strenuous training exercise that the patient does result in tearing of the ligament hence causing the pain.

In conclusion, soap note is a necessary tool used in patient documentation and it makes it easier for nurses to implement an evidence-based practice that ensures quality healthcare is delivered to patients.

References

Quinn, R. H., Sanders, J. O., Brown, G. A., Murray, J., & Pezold, R. (2016). The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the management of anterior cruciate ligament injuries. JBJS, 98(2), 153-155.

Conchie, H., Clark, D., Metcalfe, A., Eldridge, J., & Whitehouse, M. (2016). Adolescent knee pain and patellar dislocations are associated with patellofemoral osteoarthritis in adulthood: a case-control study. The Knee, 23(4), 708-711.

Zeng, C., Yang, T., Wu, S., Gao, S. G., Li, H., Deng, Z. H., … & Lei, G. H. (2016). Is posterior tibial slope associated with non-contact anterior cruciate ligament injury?. Knee Surgery, Sports Traumatology, Arthroscopy, 24(3), 830-837.

Sihvonen, R., Englund, M., Turkiewicz, A., & Järvinen, T. L. (2016). Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study. Osteoarthritis and cartilage, 24(8), 1367-1375.

Bebeley, S. J., Yi-Gang, W., & Yang, L. (2016). Athletes’ knowledge about preventing sports injuries like Achilles Tendinitis (AT), Runner’s Knee (RK)/Patellofemoral Pain Syndrome (PFPS) and Shin Splints (SS), as prime prevention strategies in slowing the ageing process. Journal of Exercise Science and Physiotherapy, 12(1), 25.