SOAP NOTE: From Contingency Plan: Aquifer Family Medicine 11: 74-Year-Old Female with Knee Pain

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 The patient is a thin, well-groomed Caucasian female. Her hair and clothes are clean and appropriate. She appears to appropriate age. Cardiovascular The patient’s heart rhythm is regular upon assessment. 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 The patient’s skin in clean, warm, dry, and intact. The color is appropriate for ethnicity.. No bruising or open wounds noted to skin. Respiratory Patient has no wheezing, shortness of breath, or cough noted. Lung sounds are clear to auscultation bilaterally. Respiratory Rate: 18 breaths/minute Eyes PERRLA. The patient has no complaints of recent or sudden changes in vision of any kind. She does not wear corrective lenses. Gastrointestinal The patient’s abdomen is soft and nontender with no masses noted with palpitation. Ears Patient has no complaints of pain or discomfort in ears. She has no discharge from the ears. Non tinnitus or hearing loss. Genitourinary/Gynecological Unremarkable. Patient has no complaints of urinary frequency, urgency, or pain/discomfort with urinating. Nose/Mouth/Throat NOSE: The patient’s nasal mucosa is intact and pink. Her nasal turbinates are WNL. She denies any nasal congestion or drainage. The patient has no septal deviation. MOUTH: The patient’s oral mucosa is pink and intact. Teeth are clean and intact. No halitosis. THROAT: The patient denies any throat pain. The oral mucosa is intact, pink and moist. Her teeth are clean and intact. There is no inflammation or drainage. Musculoskeletal Patient complains of pain in right knee. She has some tenderness in the joints of her right leg with palpation. ROM is 120 degrees in her right leg. She does have some crepitus in right patellar with movement. Normal range of motion with hips and ankles. Does report some lower back pain. Breast The patient’s breast without tenderness, lumps, masses, or discharge. The nipples are intact Neurological Patient is alert and oriented x4. Patient’s cranial nerves intact. She has full strength in bilateral upper and lower extremities. Sensation grossly intact. His speech is clear. Patient denies any headaches or blurred vision. Heme/Lymph/Endo The patient has no swollen lymph nodes. No complaints of heat or cold intolerance. No night sweats, weight gain/loss, appetite changes, etc. Psychiatric The patient is oriented to person, place, and situation. Doesn’t have any hallucinations or delusions. Reports no feelings of sadness, depression, or hopelessness. OBJECTIVE Weight (not reported ) BMI Temp 37.1 BP 130/80 Height (not reported) Pulse 64 Resp 18 General Appearance The patient is a thin, well-groomed Caucasian female. Her hair and clothes are clean and appropriate. She appears to appropriate age. Skin The patient’s skin in clean, warm, dry, and intact. The color is appropriate for ethnicity.. No bruising or open wounds noted to skin.