SOAP Note
Subjective:
Mr. Brown is a 45-year-old male teacher who presents to the clinic with a chief complaint of right knee pain following a fall at home one week ago. The patient describes the pain as sharp and stabbing immediately after the fall, and he was unable to walk straight or put weight on the knee. He applied ice and took 800mg of Motrin and went to bed. After 24 hours, he started applying warm compresses intermittently and taking extra strength Tylenol as needed. The pain has been mitigated by the use of Tylenol, heat application, and resting the knee, but there are times when the pain is so severe that even Tylenol does not help. Aggravating factors for the pain include standing for long periods, bending the knee, and climbing stairs. The patient also reports a feeling that “something is not right inside the knee” at present. On a pain scale of 0 to 10, with 10 being the worst pain, Mr. Brown rates his current pain level as 8/10. He denies any previous musculoskeletal injuries.
Medical History:
Mr. Brown has a history of asthma and bipolar disorder. He underwent surgery for a left knee anterior cruciate ligament (ACL) injury 10 years ago, and he had a right hip replacement 15 years ago due to a kickboxing injury. His current medication regimen includes Theophylline, Prednisone, Singular, Geodon, Prozac, and Benadryl. He denies any known allergies. In his family history, he has one brother with asthma, another brother with bipolar disorder, and a maternal aunt with type II diabetes. He is up to date with immunizations and does not smoke, drink alcohol, or use recreational drugs. He follows a regular diet and exercises three times a week. Mr. Brown has been married for 10 years and lives with his wife and two children. He works as a mathematics teacher in the same high school where he attends the clinic. He reports sleeping well.
Objective:
On physical examination, the patient appears well-nourished and in no apparent distress. Vital signs are stable, with a blood pressure of 120/80 mmHg, a heart rate of 80 beats per minute, a respiratory rate of 14 breaths per minute, and a temperature of 98.6°F. The patient’s height is 5’10” and weight is 180 lbs, resulting in a body mass index (BMI) of 25.8 kg/m^2. Skin is intact and without any visible abnormalities. Inspection of the right knee reveals no significant swelling, redness, or deformities. Palpation elicits tenderness over the medial aspect of the joint line and the patella. Range of motion of the knee is decreased, with pain reported during flexion and extension. Strength testing demonstrates normal muscle function in the lower extremities. Neurovascular examination is within normal limits.
Primary Diagnosis:
The primary diagnosis for Mr. Brown is acute knee pain secondary to a fall with possible internal derangement of the knee joint.
Differential Diagnoses (DDx):
1. Meniscus tear: A tear in the meniscus could have occurred during the fall, leading to pain, swelling, and difficulty with knee movements (Maffulli, Kormas, Almekinders, & Bressi, 2019).
2. Ligament sprain: The fall may have caused a sprain of one of the knee ligaments, such as the medial collateral ligament (MCL) or the anterior cruciate ligament (ACL), resulting in pain, instability, and difficulty with weight-bearing (Evans & Putnam, 2016).
3. Patellofemoral pain syndrome: The twisting motion during the fall may have caused irritation and inflammation of the patellofemoral joint, leading to anterior knee pain aggravated by activities such as climbing stairs and squatting (Crossley, Barton, & Van Middelkoop, 2015).
Diagnostic Testing:
To confirm the diagnosis and evaluate the extent of the knee injury, further diagnostic testing may include an X-ray of the knee to rule out fractures or bony abnormalities and an MRI to assess for ligament or meniscal tears.
Management Plan:
The initial management plan for Mr. Brown’s knee pain includes a multimodal approach. Non-pharmacological measures such as rest, ice, compression, and elevation (RICE), along with gentle range of motion exercises, can help reduce pain and swelling. Pharmacological measures may include analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief and short-term use of opioids if necessary. Referral to physical therapy for strengthening and rehabilitation exercises will be considered if conservative measures are insufficient.
Medications:
1. Ibuprofen 800mg every 6 hours as needed for pain relief.
2. Oxycodone 5mg every 4-6 hours as needed for breakthrough pain.
Non-pharmacological Approach:
1. Rest the affected knee and avoid activities that exacerbate the pain.
2. Apply ice packs to the knee for 15-20 minutes every 2 hours.
3. Compress the knee with an elastic bandage to reduce swelling.
4. Elevate the leg on a pillow or cushion to reduce edema.
Follow-up:
A follow-up appointment will be scheduled in one week to reassess the patient’s pain level and monitor for any improvement. If the symptoms persist or worsen, further evaluation and consideration of referral to an orthopedic specialist will be necessary.
Patient Education and Health Promotion:
During the visit, the patient will be educated about the importance of adhering to the prescribed treatment plan, including rest and medication use. The patient will be advised to avoid activities that aggravate the pain and to gradually increase activity levels as tolerated. Proper techniques for applying ice and compression will be demonstrated, and the patient will be informed about potential complications to watch for, such as increasing pain, swelling, or signs of infection. Additionally, the importance of completing the recommended follow-up appointment will be emphasized, along with the role of physical therapy in the rehabilitation process.
References:
Crossley, K. M., Barton, C. J., & Van Middelkoop, M. (2015). Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis, and patient-reported outcome measures. Journal of Orthopaedic & Sports Physical Therapy, 45(4), 1-18.
Evans, P., & Putnam, S. H. (2016). Physical examination of the knee. Primary Care: Clinics in Office Practice, 43(2), 257-274.
Maffulli, N., Kormas, V., Almekinders, L. C., & Bressi, F. (2019). Arthroscopic meniscectomy and meniscal repair: the role of rehabilitation. Journal of Orthopaedics and Traumatology: Official Journal of the Italian Society of Orthopaedics and Traumatology, 20(1), 15.
