SOAP Note Assessing Musculoskeletal Pain Example

SOAP Note Assessing Musculoskeletal Pain Example. Case to use, 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 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? joint pain soap note

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Episodic/Focused Note SOAP Note Assessing Musculoskeletal Pain

Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

Patient Initials: ____TP___ Age: __15 years_____ Gender: __Male _____

SUBJECTIVE DATA: – low back pain soap note example

Chief Complaint (CC): Dull pain in both knees.

History of Present Illness (HPI): The teenage patient (TP) who is 15 years old presents at the clinic with complaints of dull pain in both knees. According to him, there is no knee swelling although on or both legs click and the patient describes it as a catching sensation under the patella. The boy is accompanied by his father who is a reliable informant and can give an additional history to determine the likely causes of the knee pain. The father is unsure of what exactly may have triggered it but admits the boy may have improperly used sports equipment or poor training techniques. The boy also reports having changed his footwear in the last five days and using hard playing surfaces on the basketball pitch and accidentally landing in an uncomfortable spot after a fall. The patient has a history of a right knee injury that prompted the family to put a brace on it and to use crutches though they did not seek medical attention.

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Using LOCATES

The location of the pain is around the knee cap (patella), onset/context entails dull pain when squatting or climbing stairs, or sitting for long periods of time accompanied by a crackling or popping sound in the knee when standing. Character of the pain is dull with associated symptoms as described above. Timing is when standing, climbing stairs or sitting for long periods of time and gets worse at night. Relieving factors include pain medication Motrin 600mg. According to the boy the pain severity is 6/10.

Medications: 

Motrin 600 mg on a pro re nata basis.

 Allergies: No known drug adverse reactions

Past Medical History (PMH): 

Illness and Trauma: Right knee injury three months ago

Negative for history of hospitalization.

Emotional/psychiatric history TP admits low spirits and cannot cope with the knee pain. musculoskeletal soap note course hero

Past Surgical History (PSH):

Negative for any surgical operation

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Sexual/Reproductive History:

Denies any sexual history

Personal/Social History:

Denies smoking or tobacco products use

Denies ETOH or illicit drug use.

Immunization History:

Father reports all immunization are up to date but with no proof. The boy got all his immunization by age 12 He receives his flu shot annually and received Hepatitis A vaccine.

Pfizer Covid Vaccine – December 20, 2021.

Significant Family History:

Father admits to having a high stress job positive for high blood pressure and is on medications. Mother deceased c/o weight issues. Elder brother in college with weight issues but not on medication. Younger sister in elementary school with weight issues and generally healthy.

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Lifestyle:

In high school, a basketball player and devoted Southern Baptist Church Member.

Review of Systems:

General: Admits having challenges falling asleep or staying asleep, denies medical conditions

HEENT: No issues with eyes or vision, does not use glasses, negative for difficulties in hearing or ear discharge no use of hearing aids. Negative for nasal bleeds olfactory sense intact, no taste or smell issues. No sore throat, no mouth or throat issues. Regularly attends dentist visit every 3 year with last appoint being 9 months ago,

Neck: Denies pain, injury, or history of disc disease or compression.

Breasts: Not applicable

Respiratory: None contributory

CV: Negative for palpitation, denies chest pain.

GI: Negative for diarrhea, constipation no blood in his stool, denies abdominal pain

GU: No issues with bowel movements or emptying the same.

MS: Negative musculoskeletal pain except the dull pain in booth knees.

Psych: Father reports the patient has no past psychiatric history but hastens to add that TP has manifested low spirits in last five days.

Neuro: Negative for syncope or headache.

Integument/Heme/Lymph: Has normal skin color and turgor, negative for skin rashes and no bleeding disorders.

Endocrine: Negative for excessive thirst or frequent urination

Allergic/Immunologic: NKDA

OBJECTIVE DATA

 Physical Exam:

Vital signs: BP- 107/73  T-37.1 ⁰C, P-87, R-17, Ht 5’6’’ Wt- 70.4kg BMI- 25.01

General: A&O x3, but seems moderately uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyroid swelling

Chest/Lungs: Lungs negative for wheezing, and negative for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop;

ABD:  nabs x 4, No internal organs tumor; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: Patient objected to this exam

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Musculoskeletal: symmetric muscle development but reports pain in the knee cap area

Neuro: CN II – XII negative for any issues, DTR’s intact

Skin/Lymph Nodes: Negative for edema, clubbing, or cyanosis; no palpable nodes

 Diagnostics/Lab Tests and Results:

CBC – WBC 15,000 with + left shift

Knee X-ray

Covid PCR-negative

ASSESSMENT:

Kneecap pain can be categorized in three main group’s namely acute injury if there is evidence of broken bone, meniscal tear or torn ligament, medical conditions like infections or osteoarthritis and lastly chronic use or overuse conditions like tendinitis, and bursitis among others.

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Differential Diagnosis (DDx):

1. Patellofemoral pain syndrome (PFPS)- confirmed

TP could be suffering from PFPS which manifests as pain around and under the patella (kneecap). This condition is also referred to as a runner’s knee and is non-discriminatory in its infection as both adults and children suffer from it (Manske & Davies, 2016). The condition is known to affect both knees and this characteristic pain increases with either activity or sitting for an extended duration of time. The diagnosis was confirmed following a physical examination and an- ray to rule out other medical conditions that may cause pain. The various tests conducted during the knee evaluation test are the dial test, valgus stress test 0-30 degrees, Varus Stress test 0-30 degrees test, Pivot Shift test, and Reverse Shift Test. Additional tests carried out were Mc Murray’s Test, Lachman’s test, and posterior drawer test(Bunt et al, 2018). Due to the limited scope of this SOAP Note, only three of the tests will be highlighted. McMurray’s test, test demonstrates whether there is pain or painful click as the knee is brought from flexion to extension by either external or internal rotation. During this test, the patient is made to lie supine with a hyper-flexed knee.  A positive test is accompanied by clicking, popping or pain within the joint suggestive of a tear in the medial or lateral meniscus the moment the knee is brought from extension to extension. (musculoskeletal pain soap note)

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• Osgood –Schlatter disease (OSD)–Refuted

OSD is a condition that causes pain and swelling below the knee joint. Seyfettinoğlu, et al (2020) note that the diagnosis of OSD whose symptoms are confused with those of PFPS. OSD pain is located at the top of the shin bone while PFPS pain is located around the patella.

• Sinding-Larsen-Johansson (SLJ) syndrome- Refuted

SLJ has symptoms like pain that increases with exercise or activities and gets worse when kneeling or squatting. However, it was ruled out because the patient did not have a swollen or bony bump at the bottom of the kneecap.

• Patellar Tendinopathy- Refuted

Both PFPS and Patellar tendinopathy may have overlapping symptoms but runner’s knee results from the veering off of the patient’s kneecap off the patellar while the jumper’s knee occurs when the tendon connecting the patient’s shinbone to the kneecap gets inflamed (Malliaras et al, 2015). Another distinctive feature of patellar tendinopathy is pain localized to the inferior pole of the patella and pain attributed to increasing demand for knee extensors. Likewise Lachman’s test tests for anterior cruciate ligament (ACL) injury. To conduct the Lachman test, the patient should lie supine and be completely relaxed, then bend the knee to about 20-30 degrees. If the ACL is intact m and the tibia is pulled forward, the examiner should feel a firm endpoint but in case of a ruptured ACL, the examination will feel soft with no endpoint.

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• Chondromalacia patellae- Refuted

According to Ozel (2020), while chondromalacia patellae clinical manifestations reflect those of PFPS. The former term refers the pain at the front of the knee but which is not attributable to severe problems hence it was refuted. The third and last of the knee examination tests to be highlighted is pivot shift test that specifically tests for ACL deficient knee. It was ruled out because it manifests mostly in chronic settings whereas PT had an acute onset. The examiner should hold the knee in full extension then add valgus force plus internal rotation of the tibia to increase the knee’s rotational instability. A palpable clunk would indicate an ACL tear.

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PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

References

 Bump, J. M., & Lewis, L. (2021). Patellofemoral Syndrome. StatPearls [Internet].

Bunt, C. W., Jonas, C. E., & Chang, J. G. (2018). Knee pain in adults and adolescents: the initial evaluation. American family physician, 98(9), 576-585.

Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral pain syndrome. American family physician, 99(2), 88-94.

Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy, 45(11), 887-898.

Manske, R. C., & Davies, G. J. (2016). Examination of the patellofemoral joint. International journal of sports physical therapy, 11(6), 831.

 Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (SOAP Note Assessing Musculoskeletal Pain Example).

Özel, D. (2020). The relationship between early-onset chondromalacia and the position of the patella. Acta Radiologica, 61(3), 370-375.

Seyfettinoğlu, F., Köse, Ö., Oğur, H. U., Tuhanioğlu, Ü., Çiçek, H., & Acar, B. (2020). Is there a relationship between patellofemoral alignment and Osgood–Schlatter disease? A case-control study. The journal of knee surgery, 33(01), 067-072.

Zheng, W., Li, H., Hu, K., Li, L., & Bei, M. (2021). Chondromalacia patellae: current options and emerging cell therapies. Stem Cell Research & Therapy, 12(1), 1-11.

Discussion:

Assessing Musculoskeletal Pain

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RF The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. To prepare: By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format.
Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

Review the following case studies:

Case 1: Back Pain Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Case 2: Ankle Pain Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler\’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.

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A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a \”pop.\” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

Case 3: Knee Pain Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.

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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? With regard to the case study you were assigned:

Review this week\’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

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Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition.

How would the results be used to make a diagnosis? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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