SOAP Note Assignment on a Case Study of 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?  Comprehensive SOAP Analysis of a 15 years malePatient Initials: J.N          Age: 15 years                        Gender: Male SUBJECTIVE DATA:Chief Complaint (CC): The patient complains of a dull pain on both of his knees with either one or both knees clicking.  He also catches a sensation under the patella.

During the assessment procedure, the patient will be asked about: onset of symptom of pain (acute/gradual), location of the pain, duration (recent/chronic), character of pain, associated symptoms/aggravating factor, relieving factors, treatments previously tried – response? Why it was discontinued, and severity of the pain. History of Present Illness (HPI): J.N. is a 15 years Asian male who arrives at the clinic due to dull pain on both knees. He explains that at times, either one or both of his legs clicks. He continues to explain that under his patella, he experiences a catching sensation. The dull pain on his knees started approximately one and a half months ago. He states he has no other pains apart from the stated ones. He indicates that the pain is not accompanied with nausea. However, the pain is increased by exertions like running or squatting. Some of the drugs he has taken to try and relieve the pain include Aleve and other NSAIDS but provides no pain relief. On a point scale of 10, the patients explains he experiences an 8/10 form of pain. Medications: From onset, he never visited a health facility but buys over the counter drugs to try and relieve the pain. From onset, J.N has been taking Aspirin and Ibuprofen every night.Allergies: The patient has no allergies to both environmental allergens and medication allergies. Past Medical History (PMH): For the past 5 years, he has been struggling with overweight with a BMI above normal. He manages the condition through regular exercise and diet regime. As a child, he had tonsillitis that led to tonsillectomy. Past Surgical History (PSH): No history of surgeriesSexual/Reproductive History: Denies being sexually activePersonal/Social History: never abused drugs but tried tobacco once. Socially, JN loves sports where he runs trucks and plays baseball in school. He lives in a 2 storey building and his bedroom is on the left wing first floor. Immunization History: His childhood immunization is up to date

Significant Family History: JN has two siblings – a 10-year-old sister and 7-year-old brother. His parents are alive. 3 years ago, the father was diagnosed with hypertension and the mother has diabetes from 2013 and is obese. His sister has no illness history but the brother has rheumatoid fever for 1.5 years now. 

Lifestyle: He is an Asian and follows the Asian culture

Review of Systems

General: JN reports “as healthy as can be” (-) fatigue, (-) weakness, (+) recent weight gain, (-) chills, and (-) fever. He underwent a physical exam 3 years ago. 

Skin, hair, & nails: (-) changes in nails, (-) changes in hair, and (-) changes in skin 

HEENT: Head- (-) hair loss, (-) headaches (-) injury Eyes– (-) photosensitivity (+) watery eyes (-) decreased vision (the last time he had an eye exam was 2015) Ears– (-) drainage (-) ear pain (-) tinnitus (-) hearing problems Nose- (-) epistasis (-) nasal drainage (-) allergies (-) nasal congestion Throat– (-) pain or difficulty with swallowing (-) sore throat

Respiratory: (-) asthma (-) allergies (-) lung disease (-) chest pain

Cardiovascular/Peripheral Vascular: (-) hypertension (-) murmurs (-) irregular heartbeat (-) chest pain

Gastrointestinal: (-) diarrhea (-) bloating (-) abdominal pain (-) nausea (-) vomiting

Genitourinary: (-) bleeding with urination, (-) flank pain (-) burning (-) nocturia (-) incontinence (-) hesitancy (-) urinary frequency

Musculoskeletal: (+) injury to lower back, (-) trauma 

Psychiatric: (-) excessive life stresses, (-) memory loss, (-) nightmares, (-) sleep trouble, (-) desire to harm self/others, (-) frequent unhappiness, (-) hearing voices, (-) mood changes, (-) panic attacks, (-) nervousness (-) anxiety (-) trouble concentrating. There has been no recent deaths in the family or close friends. 

Neurological: (+) burning in feet, (-) numbness in feet, (-) tremors in right hand, (-) frequent/incapacitating headache, (-) seizures, (-) history of stroke

Hematologic: (-) ease of bleeding, (-) bruising, (-) heat/cold intolerance, (-) thyroid problems, (+) type I or II DM

OBJECTIVE DATA:

Physical Exam:

Vital signs: B/P 130/80, P70, R20 T97.8, BMI 29, W190, H5’8

General: JN is friendly and well groomed, maintains eye contact

HEENT: The scalp is pink and dry; each eye has a 20/20 vision, with pink conjunctiva and white sclera. His acuity is good during whispers; the nose does not have discharge or flaring. The throat membrane is moist and pink with tonsils slightly swollen. 

Neck: lobes not felt, neck supple

Chest: Pink an moist membrane

Lungs: respiration rate 12 breaths every minute producing a vesicular sound

Heart: On auscultation, the apical pulse is 90 bpm

Peripheral Vascular: No edema, warm, painful on palpation, calves not tender

Abdomen: No pain on palpation, no bruits

Genital/Rectal: Deferred at patient’s request

Musculoskeletal: Normal gait 

Neurological: Maintains balance while eye closed 

Skin: Warm and dry skin

ASSESSMENT:

Diagnosis: Patella tendinitis 

Schwartz, Watson, and Hutchinson (2015) explain that tendinitis is an anterior knee pain over the patella tendon. The pain worsens due to prolonged sitting, running, landing, or jumping. It has a gradual onset, which increases due to sport activities. More diagnosis required through an ultrasound scan or MRI. 

Differential diagnosis:

1. Bursitis
2. Gout
3. Chondromalacia patella
4. Rheumatoid arthritis (RA)
5. Osteoarthritis

Treatment Plan: 

Provide drugs for pain relief like Nonsteroidal anti-inflammatory drugs (NSAIDS) like gabapentin (Neurontin) 300mg TID or Ibuprofen 300 mg QID. JN requires to be instructed on the side effects of Neurontin, which according to (Edmunds & Mayhew, 2014), causes drowsiness. JN may require a short term bedrest of 12 hours to alleviate the pain. 

Health Promotion: JN will be educated on the varying ways to stretch to help with lower body flexibility. This can be attained through stretch-bands

REFLECTION

JN faces a gradual mild pain on both knees under the patella. Based on the past and family history, JN is overweight. On treatment, he should continue with Ibuprofen to relieve the pain. Treatment should be taken alongside physiotherapy like stretching. 

References

Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for the primary care provider (4th ed.). St. Louis, MO: Elsevier Mosby.

Schwartz, A., Watson, J. N., & Hutchinson, M. R. (2015). Patellar tendinopathy. Sports health, 7(5), 415-420.