Medial knee osteoarthritis SOAP Note
Instructions
Select a client from clinical experience with an acute health problem or complaint requiring at least two visits. Submit a complete H & P from the initial visit with this client and a focused SOAP note for the follow-up visit. Based on this client’s condition, conduct a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer-reviewed articles must address the standardized procedure or guidelines for this diagnosis. Incorporate the research findings into the decision-making for this client’s treatment.
In the paper, compare and contrast or address how treatment or the plan may have been different based on the research findings. The discussion on relating research to practice should be 3-4 pages and the total paper should be no longer than 10 pages including references. The research articles must be original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Cover the criteria listed below. The paper should be APA formatted and no longer than 10 pages.
Solution
SOAP Note
Client’s Initials: B.P, Age: 46, Race: Hispanic, Gender: Female, Date of Birth: 04-15-1975.
SUBJECTIVE:
Chief Complaint: “I cannot bear weight on my right knee. It is painful to walk on it”
HPI: B.P is a pleasant 46-years-old Hispanic female. Presents with right knee pain. Denies any trauma to her knee. The patient stated that her daughter drove her to the clinic. She appears uncomfortable and appears to be a reliable historian. She reported that the onset of pain started five days ago. Location of the pain is medial aspect of the right knee.
Duration of the pain is constant. Characteristic of the pain is sharp in nature. Aggravating factor is weight bearing on the right knee. Relieving factor of the pain is a knee brace she purchases from the local pharmacy. Treatment has been Tylenol and Motrin with minimal relief.
Past Medical History: Iron deficiency anemia, Gastro-esophageal reflux disease, Cervicalgia, Season allergic rhinitis.
Allergies: No Known drug allergies, lactose intolerance.
Surgical Hx: Appendectomy.
Medication: Pantoprazole 20 mg daily, Zyrtec 5 mg as needed, Tylenol 100 mg as needed Motrin 800 mg as needed.
Vaccination: Flu shot, 11/2020, Covid- 19 first shot (Pfizer), 8/10/2021.
Social Hx: Denies any Tobacco/ cigarette or alcohol use.
Family Hx: Dad died of alcohol abuse at age 51, Mom has complication from irritable bowel syndrome, and diabetes.
Review of Systems:
General: B. P. denies abnormal changes in body weight in the past one month. She denies fever.
HEENT:
Head: Denies head trauma or physical head injury. No headache reported.
Eyes: Denies a blurry vision. Denies eye pain.
Ears: No ear pain or hearing problems reported.
Nose: Denies sneezing, denies nasal congestion. No nasal pain reported.
Throat: Denies a sore throat.
Neck: Does not report pain or swelling in the neck region.
Respiratory: Denies breathing difficulties. Denies congestion in the chest.
Cardiovascular/Peripheral Vascular: Does not report tightness of the chest. No chest pain reported.
Gastrointestinal: Denies stomachache, constipation, or abdominal pain.
Genitourinary: Denies increased urination frequency. Does not report any issues with the genitals.
Musculoskeletal: Reports a constant and sharp pain in the medial aspect of the right knee. The pain is aggravated by weight bearing on the knee and relieved by a knee brace.
Psychiatric: Does not report changes in mood, depression, anxiety, or memory loss.
Skin: Denies redness on the skin, skin itchiness, or rashes.
Hematologic: Does not report a history of blood-related disorders such as sickle cell disease and hemophilia.
Endocrine: No abnormal night sweats reported. Denies excessive thirst, fatigue, or frequent urination.
OBJECTIVE:
Physical Exam:
VS: BP: 130/80 (sitting), RR: 20, T: 36.6, Height: 5 feet 11 inches, Wt: 85 kg (the client is overweight at the age of 46 years, female gender).
General: B.P. appears uncomfortable and appears to be a reliable historian.
HEENT:
- Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
- Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOM are intact, PERRLA. Eyelids are normal in appearance without swelling or lesions.
- Ears: The external ear and ear canal are non-tender and without edema. The canal is clear without discharge. The tympanic membrane is normal in appearance.
- Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.
- Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar edema or exudates.
Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses. Carotid pulse 2+ bilaterally without bruit. No JVD.
Skin: Skin is warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nail Beds pink with no cyanosis or clubbing.
Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity.
Respiratory: The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields.
Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.
Genital/Rectal: Rectal exam unnecessary. No external masses or lesions.
Reproductive: External genitalia is normal in appearance without lesions, edema, masses or tenderness. Ovaries are non-tender without palpable masses or enlargement. No evidence of pain in the lower abdomen on palpation.
Musculoskeletal:
-Neck and back are without deformity, external skin changes, or signs of trauma. Posture is upright, gait is smooth, steady, and within normal limits.
-No tenderness noted on palpation of the spinous processes. Spinous processes are midline.
-Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm.
-No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort.
– Sensation to the upper and lower extremities is normal bilaterally. No clonus is noted. Grip strength is normal bilaterally.
-Extremities: Upper extremities are atraumatic in appearance without tenderness or deformity. No edema or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable.
– Lower extremities: The medial aspect of the right knee is slightly swollen and has evidence of pain on palpation. Right knee lacks full range of motion. The patient presents with an evidence of pain and discomfort when trying to stand up and when bending the knee. Has abnormal tendon function on the right knee but normal on the left. The right knee cannot bear her heavy weight.
Neurological: B.P. is awake with normal speech. Her sensation is intact bilaterally. Her motor function on the right knee is defective. She feels pain when she tries to straighten and bend her right knee. The pain is worsened when she tries to stand up.
Psychiatric: Appropriate mood and affect. Good judgment and insight. No visual or auditory hallucinations. No suicidal or homicidal ideation.
ASSESSMENT:
Differential Diagnoses:
- Medial knee osteoarthritis (Primary diagnosis)
-Risk factors present in the patient include; age above 40 years, female gender, and overweight.
- Pes anserine bursitis
- Medial meniscus injury
Plan:
Diagnostics
Perform radiographic procedures to identify the actual cause of medial knee pain.
- Knee X-ray
- Magnetic resonance imaging (MRI) of the knee
- Computed tomography (CT) scan of the knee
The American Family Physician recommends radiography as a diagnostic test for confirming all forms of osteoarthritis. The clinician should perform different types of radiographic techniques including knee x-ray, MRI of the knee, and knee CT scan to generate data that can be used to make an accurate diagnosis. It is recommended that radiography should be performed in patients with suspected osteoarthritis before any referrals for surgery are made (Ebell, 2018).
Pharmacological and Non-Pharmacological Treatment
The treatment of medial knee osteoarthritis should follow evidence-based and standardized clinical practice guidelines. The effectiveness of these guidelines have been confirmed through research. In a study conducted by Ebata-Kogure et al. (2020), the researchers discovered that patients with knee osteoarthritis were successfully treated with acetaminophen as well as topical and systemic nonsteroidal anti-inflammatory drugs (NSAIDs).
In another study, Farpour et al. (2020) found that Piroxicam Mesotherapy is a safe and effective treatment for patients with knee osteoarthritis. These two articles provide different evidence for the treatment of knee osteoarthritis. Using evidence from Ebata-Kogure et al. (2020), patient B.P. would be treated with acetaminophen as well as topical and systemic NSAIDs. However, using evidence from Farpour et al. (2020), patient B.P. would be treated with Piroxicam Mesotherapy.
Patient Education and Health Promotion:
- Educate the patient to avoid lifting heavy things. She should avoid fatty foods and exercise regularly to manage weight. B.P. should also be educated to adhere to the recommended treatment (Panunzi et al., 2021).
Referral: Refer to a physiotherapist to offer advice on exercise and appropriate physical activities.
Follow-up plan: B.P. should report to the clinic for evaluation after 2 weeks.
References
Ebata-Kogure, N., Murakami, A., Nozawa, K., Fujii, K., Lin, Y., Ushida, T., & Kikuchi S. (2020). Treatment and healthcare cost among patients with hip or knee osteoarthritis: A cross-sectional study using a real-world claims database in Japan between 2013 and 2019. Clinical Drug Investigation, 40(11):1071-1084. doi: 10.1007/s40261-020-00968-6. PMID: 32965598.
Ebell, M. (2018). Osteoarthritis: Rapid Evidence Review. American Family Physician, 97(8), 523-526. https://www.aafp.org/afp/2018/0415/p523.html.
Farpour, H. R., Estakhri, F., Zakeri, M., Parvin, R. (2020). Efficacy of piroxicam mesotherapy in treatment of knee osteoarthritis: A randomized clinical trial. Evidence Based Complementary and Alternative Medicine, 6940741. doi: 10.1155/2020/6940741. PMID: 32831875; PMCID: PMC7421712.
Panunzi, S., Maltese, S., De Gaetano, A., Capristo, E., Bornstein, S. R., & Mingrone, G. (2021). Comparative efficacy of different weight loss treatments on knee osteoarthritis: A network meta-analysis. Obesity Reviews, 22(8):e13230. doi: 10.1111/obr.13230. Epub 2021 Apr 15. PMID: 33855769.