SOAP Note
Patient: Mrs. F Age: 75 Gender: F Marital Status: Widow Race: Hispanic
SUBJECTIVE:
S CC: “Both of my knees hurt a lot”
HPI: The patient presents today for follow up of osteoarthritis of the bilateral knees. She reports that
the pain in the knees has been increasing in severity for the past 2 years. She states the pain ranges in
severity from 3 to 10 (out of 10), but since Monday this week the pain is worse rating of 7/10 in the right
knee and 5/10 in the left knee. Patient also reports that she has notice that the right knee is inflamed.
Pain is partially alleviated by rest and ibuprofen. Patient admits to stiffness (worse in morning or with
inactivity) that resolves in 5-10 minutes with movement and reduced ROM due to pain/stiffness.
PMH:
Allergies: Iodine
Childhood Illness: Recurrent tonsillitis
Adulthood illness: Osteoarthritis and Cataracts
Surgical History: Hysterectomy
Medication List: Ibuprofen 400 mg every 6 hours
FH: Mother – Lung cancer, heart disease, hypertension, diabetes. Father – Diabetes. bother –
Alcoholism.
SH: Patient has history of smoking for 27 years. Does not drink alcohol. She is retired, currently
living with a daughter. Patient does not have a regular exercise routine. Patient states that she tries
to eat healthy food but she is unable to lose weight because of her incapacity of do exercises due to
the pain ROS
Constitutionals: Denies fevers, chills, fatigue, malaise, and headache.
Head/Eyes: Denies ear pain, fullness, popping, loss of hearing, or drainage. Denies blurry vision, eye
pain, itching, or drainage.
ENMT: Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore throat, loss of taste,
difficulty swallowing, and bleeding gums. Denies tooth pain, gum pain, and difficulty chewing.
Cardiovascular: Denies chest pain, palpitations, syncope, and shortness of breath. Denies palpitations,
orthopnea, and syncope.
Respiratory: Denies cough and sputum production. Gastrointestinal:
Denies nausea, vomiting, constipation, melena, indigestion, reflux, dysphagia, diarrhea, and loss of
appetite.
Genitourinary: Bilateral lower quadrant abdominal pain/pressure. Complains of dysuria, polyuria,
burning, frequency, and incomplete bladder emptying, without hematuria, offensive odor of urine, or
back/flank pain.
Musculoskeletal: Patient reports bilateral knee pain, right knee pain 7/10 and left knee pain 5/10. She
also reports inflamed right knee articulation. Reports stiffness of muscle/joints in the morning with
some, limitations to ROM. Denies muscle cramps, deformities and weakness.
Integumentary: Denies rashes, new moles, itching, acne, or other skin changes.
Neurological: Denies memory loss, imbalance, weakness, paralysis, numbness, tingling, tremors,
disorientation, speech disorders and involuntary movements.
Patient: Mrs. F Age: 75 Gender: F Marital Status: Widow Race: Hispanic
SUBJECTIVE:
S CC: “Both of my knees hurt a lot”
HPI: The patient presents today for follow up of osteoarthritis of the bilateral knees. She reports that
the pain in the knees has been increasing in severity for the past 2 years. She states the pain ranges in
severity from 3 to 10 (out of 10), but since Monday this week the pain is worse rating of 7/10 in the right
knee and 5/10 in the left knee. Patient also reports that she has notice that the right knee is inflamed.
Pain is partially alleviated by rest and ibuprofen. Patient admits to stiffness (worse in morning or with
inactivity) that resolves in 5-10 minutes with movement and reduced ROM due to pain/stiffness.
PMH:
Allergies: Iodine
Childhood Illness: Recurrent tonsillitis
Adulthood illness: Osteoarthritis and Cataracts
Surgical History: Hysterectomy
Medication List: Ibuprofen 400 mg every 6 hours
FH: Mother – Lung cancer, heart disease, hypertension, diabetes. Father – Diabetes. bother –
Alcoholism.
SH: Patient has history of smoking for 27 years. Does not drink alcohol. She is retired, currently
living with a daughter. Patient does not have a regular exercise routine. Patient states that she tries
to eat healthy food but she is unable to lose weight because of her incapacity of do exercises due to
the pain ROS
Constitutionals: Denies fevers, chills, fatigue, malaise, and headache.
Head/Eyes: Denies ear pain, fullness, popping, loss of hearing, or drainage. Denies blurry vision, eye
pain, itching, or drainage.
ENMT: Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore throat, loss of taste,
difficulty swallowing, and bleeding gums. Denies tooth pain, gum pain, and difficulty chewing.
Cardiovascular: Denies chest pain, palpitations, syncope, and shortness of breath. Denies palpitations,
orthopnea, and syncope.
Respiratory: Denies cough and sputum production. Gastrointestinal:
Denies nausea, vomiting, constipation, melena, indigestion, reflux, dysphagia, diarrhea, and loss of
appetite.
Genitourinary: Bilateral lower quadrant abdominal pain/pressure. Complains of dysuria, polyuria,
burning, frequency, and incomplete bladder emptying, without hematuria, offensive odor of urine, or
back/flank pain.
Musculoskeletal: Patient reports bilateral knee pain, right knee pain 7/10 and left knee pain 5/10. She
also reports inflamed right knee articulation. Reports stiffness of muscle/joints in the morning with
some, limitations to ROM. Denies muscle cramps, deformities and weakness.
Integumentary: Denies rashes, new moles, itching, acne, or other skin changes.
Neurological: Denies memory loss, imbalance, weakness, paralysis, numbness, tingling, tremors,
disorientation, speech disorders and involuntary movements.
