1|Page
IHUMAN CASE STUDY FOR A 57 YEARS OLD MALE
TOD GOUSEAU ON EVALUATION OF LEFT KNEE
PAIN - NURS 6512 WEEK #10 FOR WALDEN
UNIVERSITY FINAL DIAGNOSIS: CONGESTIVE
HEART FAILURE INCLUDING SOAP NOTE, HPI, PE,
DIFFERENTIAL DIAGNOSIS AND MANAGEMENT
PLAN|| LOCATION; OUTPATIENT CLINIC WITH X-
RAY, ECG, AND LABORATORY CAPABILITIES
LATEST AND COMPLETE GRADED A+
, 2|Page
History Assessment ·r. DB]'s s
Asked X Not asked
Information
Graded Approach Question Response Obtained Clinic
Notes
My left knee is killing me. And
•
when my daughter saw that I
CC Sx How can I help you today? was limping and how red the
knee was, she insisted that I
come in and get it checked out.
Do you have any other
•
Nope, just the knee pain and
Assoc Sx symptoms or concerns we
swelling.
should discuss?
• Assoc Sx Have you been having fevers? Nope -- no fever, no chills.
No. Initially I thought I must
have hurt it at some point, but I
•
Have you had any trauma to can't recall injuring it. The skin
Etiology your knee(s)? on the knee looks red, almost
like a sunburn, but I don't
remember hurting or bruising it.
OLD-CARTS for the HPI
Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
-
• Onset
When did the pain in your
knee(s) start?
Two days ago it was just a mild
ache, but now it really hurts.
•
With the pain but is getting
Onset When did your swelling start? worse over the last couple of
days.
•
Does the pain in your knee(s)
It doesn't move anywhere. It's
Location radiate someplace else?
just in my left knee.
Where?
Duration I
I
•
Does the pain in your knee(s)
No, it's there constantly.
Characteristics come and go?
, 3|Page
Physical
History Assessment Test Result Diagnosis Summary
Exam
+ - +
The knee pain? Now that you
r ask, I did have some knee pain
• Characteristics
Have you had pain in your
knee(s) before?
last year. I think it was the same
knee. It wasn't this bad and it
went away pretty fast. Do you
think it was the same thing?
I had slight knee swelling about
• II
Characteristics
Have you had swelling like this a year ago now that you
before? mention it, but nothing like
- today.
Is the pain in your knee(s)
It feel like both inside and
X Characteristics superficial (on the surface) or
deep inside? outside.
I
I It started as an ache. Then it
• Characteristics
What does the pain in your
knee(s) feel like?
turned into a throbbing pain.
Today I'm having trouble walking
because it hurts so much.
+
It tends to feel better if I rest, but
it doesn't go away. I tried
• Aggravating
Does anything make the pain in ibuprofen, but that isn't helping. I
your knee(s) better or worse? haven't tried ice or anything. Do
you think I should? Walking and
I bending hurts a hell of a lot.
Relieving I
-
• I
How often does your knee pain
Timing/Treatments occur?
--
This is the first time I have ever
had knee pain like this.
About 6-8 out of 10, depending
•
How severe (1-10 scale) is the
on what I'm doing. Can't put
Severity pain in your knee(s)?
weight on it.
HPI
I
IHUMAN CASE STUDY FOR A 57 YEARS OLD MALE
TOD GOUSEAU ON EVALUATION OF LEFT KNEE
PAIN - NURS 6512 WEEK #10 FOR WALDEN
UNIVERSITY FINAL DIAGNOSIS: CONGESTIVE
HEART FAILURE INCLUDING SOAP NOTE, HPI, PE,
DIFFERENTIAL DIAGNOSIS AND MANAGEMENT
PLAN|| LOCATION; OUTPATIENT CLINIC WITH X-
RAY, ECG, AND LABORATORY CAPABILITIES
LATEST AND COMPLETE GRADED A+
, 2|Page
History Assessment ·r. DB]'s s
Asked X Not asked
Information
Graded Approach Question Response Obtained Clinic
Notes
My left knee is killing me. And
•
when my daughter saw that I
CC Sx How can I help you today? was limping and how red the
knee was, she insisted that I
come in and get it checked out.
Do you have any other
•
Nope, just the knee pain and
Assoc Sx symptoms or concerns we
swelling.
should discuss?
• Assoc Sx Have you been having fevers? Nope -- no fever, no chills.
No. Initially I thought I must
have hurt it at some point, but I
•
Have you had any trauma to can't recall injuring it. The skin
Etiology your knee(s)? on the knee looks red, almost
like a sunburn, but I don't
remember hurting or bruising it.
OLD-CARTS for the HPI
Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
-
• Onset
When did the pain in your
knee(s) start?
Two days ago it was just a mild
ache, but now it really hurts.
•
With the pain but is getting
Onset When did your swelling start? worse over the last couple of
days.
•
Does the pain in your knee(s)
It doesn't move anywhere. It's
Location radiate someplace else?
just in my left knee.
Where?
Duration I
I
•
Does the pain in your knee(s)
No, it's there constantly.
Characteristics come and go?
, 3|Page
Physical
History Assessment Test Result Diagnosis Summary
Exam
+ - +
The knee pain? Now that you
r ask, I did have some knee pain
• Characteristics
Have you had pain in your
knee(s) before?
last year. I think it was the same
knee. It wasn't this bad and it
went away pretty fast. Do you
think it was the same thing?
I had slight knee swelling about
• II
Characteristics
Have you had swelling like this a year ago now that you
before? mention it, but nothing like
- today.
Is the pain in your knee(s)
It feel like both inside and
X Characteristics superficial (on the surface) or
deep inside? outside.
I
I It started as an ache. Then it
• Characteristics
What does the pain in your
knee(s) feel like?
turned into a throbbing pain.
Today I'm having trouble walking
because it hurts so much.
+
It tends to feel better if I rest, but
it doesn't go away. I tried
• Aggravating
Does anything make the pain in ibuprofen, but that isn't helping. I
your knee(s) better or worse? haven't tried ice or anything. Do
you think I should? Walking and
I bending hurts a hell of a lot.
Relieving I
-
• I
How often does your knee pain
Timing/Treatments occur?
--
This is the first time I have ever
had knee pain like this.
About 6-8 out of 10, depending
•
How severe (1-10 scale) is the
on what I'm doing. Can't put
Severity pain in your knee(s)?
weight on it.
HPI
I
