Prepare a focused assessment SOAP note for a musculoskeletal condition (Knee pain). List a minimum of three differential diagnosis. The primary diagnosis must be at the top of the list. I will include the SOAP template. Also, check the Rubric for grading criteria.

 

Prepare and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. For this Assignment, you will work with a patient with a musculoskeletal condition. All Physical Exams (PE’s) in this course are focused, so you only need to examine the area of chief complaint and any pertinent history system (hx of GIB, IBS… examine the abdomen, history of DM – look at skin), and always, always, always do a cardiac and respiratory exam. 

All assignments are considered formal in this course and require APA 7.

 

Assignment:

 

  • Subjective: What details did the patient provide regarding her personal and medical history?
  •  
  • Objective: What observations did you make during the physical assessment?
  •  
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
  •  
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  •  
  • Reflection notes: What would you do differently in a similar patient evaluation?

 

Use a similar case study, where the diagnosis and differential diagnosis are the following:

  • – Primary diagnosis: Osteoarthritis
  • – Differential diagnosis: 
  •    1. Gout 
  •    2. Rheumatoid arthritis

 

Diagnostic test/Labs: Include these with results.

X-Ray

Serum uric acid

Synovial fluid analysis

Erythrocyte Sedimentation Rate (ESR)

CBC

Antinuclear antibody

 

Plan of care: This is a patient that went to a family doctor with knee pain. I need to specify what was done for the patient, not as MAY. What was prescribed? Medication, dose, frequency, and duration. What side effects might she experience, what was she told? What education was provided to her? When is her follow up?

 

Sample case study: 

Chief complaint: Knee pain.

HPI: Mrs. M. J complains of pain in her knees that stared about five years ago but has gotten worse over time. The location of her pain is inside her knees, and the pain in her right knee is worse. The pain in her right knee radiates down to her ankle. Ms. Johnson describes the pain in her knees as stiff and achy. They are stiff in the morning for about 15-20 minutes. Cold weather and exercise makes her knee pain worse. She hasn’t found anything that helps with the pain. Ms. Johnson states that her pain level is usually about a 4 or 5 out of 10, and sometimes it is a 7 or 8 out of 10. Associated symptoms with the pain are swelling in her knees and sometimes her finger knuckles.

 

 

I will attach my previous SOAP Note (Gastrointestinal). I got 94%. I want you to follow the same format. I will also include the rubric notes and the template.

 

 

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