Best Sample Focused SOAP Note (2022)
This article provides sample Episodic/ Focused SOAP Note.
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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.
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?
Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
List five different possible conditions for the patient\’s differential diagnosis, and justify why you selected each.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format.
…
Solution
Episodic/ Focused SOAP Note
Patient Information:
Initials: MO Age: 15 Sex: Male Race: White
S.
CC: ‘Dull pain in both knees’
HPI: The patient is a 15-year-old male. The patient complains of dull pain in both knees, which suddenly began a fortnight ago. He reports that sometimes both knees click and feels a catching sensation under the patella. The patient is alert and oriented X4. The patient reports tingling extremities while sitting or bending. The patient also complains of fever and nausea. The severity of the patient’s pain is 4/10 while at rest or after medication with Ibuprofen 200 mg orally and 9/10 while walking.
Current Medications: Ibuprofen 200 mg orally every 4 to 6 hours as needed for pain management and acetaminophen (OTC) mg q4-6hr to manage fever.
Allergies: NKDA on medication
PMHx: The patient sprained both knees while playing soccer at different times in the past year.
Soc Hx: The patient is a sophomore and passionate about soccer. The patient denies drug and alcohol abuse or sexual activity.
Fam Hx: Last born with two elder siblings having no medical conditions. The father, a 40-year-old with arthritis – managed through medication. The mother, a 38-year-old – has no history of a medical condition.
ROS:
GENERAL:
HEENT: Denies headache. Vision is intact. No hearing loss. Denies sore throat, cough, or sneezing
SKIN: No itching or rashes on the skin. Skin color, turgor, and moisture are intact.
CARDIOVASCULAR: No chest pain, palpation, or edema. Abnormal heart sounds.
RESPIRATORY: Denies shortness of breath, cough, or phlegm.
GASTROINTESTINAL: No abdominal pain, vomiting, or diarrhea. Experiences nausea and fever.
GENITOURINARY: Frequent urination with no burning sensation. Normal bowel sounds and tenderness.
NEUROLOGICAL: Alert and oriented X4. No dizziness/headache. Patient reports tingling of legs while bending or sitting down.
MUSCULOSKELETAL: Body posture is intact, with no muscle deformities. No pain in the upper body parts. Pain and swelling of the knees. The patient can bend and walk with discomfort.
LYMPHATICS: Lymph nodes intact.
PSYCHIATRIC: No history of psychological disorder
ENDOCRINOLOGIC: No sweat, heat, or cold intolerance
ALLERGIES: NKDA
O.
Physical exam: The system pertinent to this patient’s case is Musculoskeletal.
MUSCULOSKELETAL: Body posture is intact, with no muscle deformities. No pain in the upper body parts. Pain and swelling of the knees. The patient can bend and walk with discomfort.
Diagnostic tests: Bilateral knee X-rays, Computerised tomography (CT), Magnetic resonance imaging (MRI), the Lachman test, and Complete Blood Count (CBC).
Bilateral X-ray, MRI, and CT scans provide pictures and images of the structure of the knee crucial in evaluating the source and cause of the pain. The Lachman test is done to check the anterior cruciate ligament (ACL) for the possibility of a tear. A CBC test is used to rule out inflammatory arthritis.
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A.
Differential Diagnoses:
- Medial meniscus – The primary symptom of the medial meniscus includes knee joint pain (Wu et al., 2018). Other significant symptoms include flexing difficulty and clicking. The patient in this scenario shows these symptoms
- Overuse Injury (refuted) – This is a type of joint or muscle injury associated with fracture or tendinitis due to repetitive trauma (Arnold et al., 2017). Knee pain is a crucial symptom of overuse.
- Patella Fracture (refuted) – A condition where the kneecap is broken. Primary symptoms included pain and swelling of the knee joint (Siljander et al., 2017).
- Patellar Dislocation (refuted) – An injury associated with the kneecap slipping from a normal position. Symptoms include partial bending of the kneecap, swelling, and pain in the knee (Rudavsky & Cook, 2014).
- Knee Osteochondritis dissecans (refuted) – A condition characterized by the separation of parts of the knee bode from surrounding areas due to a shortage of blood supply. Symptoms include swelling and pain in the knees (Perdisa et al., 2017).
- Osgood–Schlatter disease (OSD (refuted) – OSC is an inflammation of the patellar ligament. Symptoms include a painful bump just below the knee (Narayan et al., 2015). The pain worsens with activity and is subsidized with rest.
Primary Diagnosis:
Medial meniscus – The primary symptom of the medial meniscus includes knee joint pain (Wu et al., 2018). Other significant symptoms include flexing difficulty and clicking. The patient in this scenario shows these symptoms.
References
Arnold, A., Thigpen, C. A., Beattie, P. F., Kissenberth, M. J., & Shanley, E. (2017). Overuse physical injuries in youth athletes: risk factors, prevention, and treatment strategies. Sports Health, 9(2), 139-147. 10.1097/JSM.0000000000000105
Narayan, N., Mitchell, P. D., & Latimer, M. D. (2015). Complete resolution of the symptoms of refractory Osgood-Schlatter disease following percutaneous fixation of the tibial tuberosity. Case Reports, 2015, bcr2014206734. http://dx.doi.org/10.1136/bcr-2014-206734
Perdisa, F., Kon, E., Sessa, A., Andriolo, L., Busacca, M., Marcacci, M., & Filardo, G. (2018). Treatment of knee osteochondritis dissecans with a cell-free biomimetic osteochondral scaffold: clinical and imaging findings at midterm follow-up. The American journal of sports medicine, 46(2), 314-321. https://doi.org/10.1177/0363546517737763
Rudavsky, A., & Cook, J. (2014). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of physiotherapy, 60(3), 122-129. https://doi.org/10.1016/j.jphys.2014.06.022
Siljander, M. P., Vara, A. D., Koueiter, D. M., Wiater, B. P., & Wiater, P. J. (2017). Novel anterior plating technique for patella fracture fixation. Orthopedics, 40(4), e739-e743. https://doi.org/10.3928/01477447-20170615-02
Wu, J. L., Lee, C. H., Yang, C. T., Chang, C. M., Li, G., Cheng, C. K., & Lai, Y. S. (2018). A novel technique for repairing posterior medial meniscus root tears using porcine knees and biomechanical study. PloS one, 13(2), e0192027. https://doi.org/10.1371/journal.pone.0192027
Question
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.
- 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?
- Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
- List five different possible conditions for the patient\’s differential diagnosis, and justify why you selected each.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format.
Please POST a SOAP Episodic/FOCUS note ONLY!
Refer to the Episodic/Focused SOAP Template. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
PLEASE READ your RUBRIC for the assignment.
Case Study: CASE #3 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?