SOAP NOTE: From Contingency Plan: Aquifer Family Medicine 11: 74-Year-Old Female with
Knee Pain
Name: Ms. Roman Date: 6/18/2020 Time: 0900
Age: 74 Sex: Female
SUBJECTIVE
CC:
"I've been having some pain in my right knee. It's really been bothering me. It feels achy
all over. I've had knee pain off and on for months, but it has become more constant for the
last several weeks. When the pain didn't seem to be going away, I decided to come see the
doctor."
HPI:
The patient is a 74-year-old Caucasian female who presents to the doctor’s office today
with the chief complaint of right knee pain. She has reports that the knee pain has been
intermittent for months, but has become more constant over the past several weeks. She
has had no injuries, and no past surgeries, but does report that she “hits her knee” while
gardening sometimes. She reports the pain as a 6 on a scale of 0-10, and reports it as a
“grinding” pain. She has some decreased range of motion and crepitus with moving the
right knee. The pain gets better with rest, and worse throughout the day with activity.
Bengay also helps with the knee pain, but she reports she has not tried to take any oral
medications.
Medications: (list with reason for med )
Multivitamin
Extra-strength Tylenol (PRN for pain)
Tums (PRN for heartburn)
PMH
GERD (patient controls with PRN Tums)
Alcohol Use Disorder
Allergies:
NKDA
Medication Intolerances:
, N/A
Chronic Illnesses/Major traumas
This patient is a 74-year-old female with a history of GERD and remote history of alcohol use disorder.
She takes no prescription drugs at home, only TUMS for heartburn, Tylenol PRN for pain, and a
multivitamin. She has no chronic illnesses, and has had no major hospitalizations. The only surgery she has
had was a tonsillectomy as a child. She has had no major traumas.
Hospitalizations/Surgeries
Tonsillectomy
Family History
Mother - Diabetes Mellitus Type 2
Osteoarthritis
Father – “Skin Problems”
Social History
Tobacco: Nonsmoker
ETOH: None – Reports she has not had a drink in several years
Illicit Drugs: None
Caffeine: 0 cups of caffeine per day.
Occupation: Retired School Teacher
lives alone in a two-story home in a rural community. Her hobby is gardening, which she enjoys daily.
ROS
General Cardiovascular
The patient is a thin, well-groomed Caucasian
female. Her hair and clothes are clean and The patient’s heart rhythm is regular upon assessment.
appropriate. She appears to appropriate age. She has normal S1 and S2 heart sounds, no S3, S4 no
heart murmur, lifts, heaves, or thrills. Reports no chest
pain
Blood Pressure: 130/80 HR: 64
Skin Respiratory
The patient’s skin in clean, warm, dry, and intact.
The color is appropriate for ethnicity.. No bruising Patient has no wheezing, shortness of breath, or cough
or open wounds noted to skin. noted. Lung sounds are clear to auscultation bilaterally.
Knee Pain
Name: Ms. Roman Date: 6/18/2020 Time: 0900
Age: 74 Sex: Female
SUBJECTIVE
CC:
"I've been having some pain in my right knee. It's really been bothering me. It feels achy
all over. I've had knee pain off and on for months, but it has become more constant for the
last several weeks. When the pain didn't seem to be going away, I decided to come see the
doctor."
HPI:
The patient is a 74-year-old Caucasian female who presents to the doctor’s office today
with the chief complaint of right knee pain. She has reports that the knee pain has been
intermittent for months, but has become more constant over the past several weeks. She
has had no injuries, and no past surgeries, but does report that she “hits her knee” while
gardening sometimes. She reports the pain as a 6 on a scale of 0-10, and reports it as a
“grinding” pain. She has some decreased range of motion and crepitus with moving the
right knee. The pain gets better with rest, and worse throughout the day with activity.
Bengay also helps with the knee pain, but she reports she has not tried to take any oral
medications.
Medications: (list with reason for med )
Multivitamin
Extra-strength Tylenol (PRN for pain)
Tums (PRN for heartburn)
PMH
GERD (patient controls with PRN Tums)
Alcohol Use Disorder
Allergies:
NKDA
Medication Intolerances:
, N/A
Chronic Illnesses/Major traumas
This patient is a 74-year-old female with a history of GERD and remote history of alcohol use disorder.
She takes no prescription drugs at home, only TUMS for heartburn, Tylenol PRN for pain, and a
multivitamin. She has no chronic illnesses, and has had no major hospitalizations. The only surgery she has
had was a tonsillectomy as a child. She has had no major traumas.
Hospitalizations/Surgeries
Tonsillectomy
Family History
Mother - Diabetes Mellitus Type 2
Osteoarthritis
Father – “Skin Problems”
Social History
Tobacco: Nonsmoker
ETOH: None – Reports she has not had a drink in several years
Illicit Drugs: None
Caffeine: 0 cups of caffeine per day.
Occupation: Retired School Teacher
lives alone in a two-story home in a rural community. Her hobby is gardening, which she enjoys daily.
ROS
General Cardiovascular
The patient is a thin, well-groomed Caucasian
female. Her hair and clothes are clean and The patient’s heart rhythm is regular upon assessment.
appropriate. She appears to appropriate age. She has normal S1 and S2 heart sounds, no S3, S4 no
heart murmur, lifts, heaves, or thrills. Reports no chest
pain
Blood Pressure: 130/80 HR: 64
Skin Respiratory
The patient’s skin in clean, warm, dry, and intact.
The color is appropriate for ethnicity.. No bruising Patient has no wheezing, shortness of breath, or cough
or open wounds noted to skin. noted. Lung sounds are clear to auscultation bilaterally.
