SOAP Note On Unilateral Primary Osteoarthritis, Right Knee ✓ Solved

SOAP Note on Unilateral Primary Osteoarthritis, right knee

SOAP Note on Unilateral Primary Osteoarthritis, right knee

Subjective:

Chief Complaint: “I have pain and inflammation in my right knee.”

History of Present Illness: A 74-year-old Hispanic female presents with complaints of pain and inflammation in her right knee. The symptoms started about 7 months ago and have been worsening. The patient reports loss of flexibility, stiffness, tenderness, and a grating sensation in the right knee while walking. She notes that symptoms worsened after gaining five pounds. Pain is sharp, rated 7/10, and limits her range of motion. Symptoms escalate with activity and subside with rest. The patient experiences stiffness upon waking. She has a history of obesity managed with medication. She occasionally uses ibuprofen for pain relief, though it provides minimal relief.

Past Medical History: Obesity diagnosed 2 years ago, managed with medication. No known medication intolerances, recent hospitalizations, or surgeries. No allergies.

Family History: The patient reports a family history of diabetes in her father and grandparents, and osteoarthritis in her father before he passed away. Her mother died in a road accident without prior health issues. She has a daughter and a son; the son is obese.

Social History: The patient is a retired social worker with a sociology degree and lives in a safe environment with her husband. She denies smoking, alcohol, or drug use and enjoys playing piano in the evenings.

Review of Systems:

• General: Denies night sweats, fatigue, chills, fever, unplanned weight gain, body aches.
• Cardiovascular: Denies palpitations, pedal edema, tachycardia, or chest pressure.
• Skin: Denies color changes, turgor issues, lesions, bruising, or rashes.
• Respiratory: Denies TB, wheezing, cough, pneumonia history, or dyspnea.
• Eyes: Denies blurred vision, pain, double vision, or corrective lens use.
• Gastrointestinal: Denies constipation, eating disorders, nausea, or abdominal pain.
• Ears/Nose/Throat: Denies pain, discharge, or hearing loss.
• Musculoskeletal: Reports pain, inflammation, loss of flexibility, stiffness, tenderness, and grating in the right knee, denies muscle pain.
• Neurological: Denies paralysis, syncope, headache, blackouts, or seizures.

Objective:

Weight: 197 lbs; BMI: 30 kg/m²; Temp: 98.1°F; BP: 120/80; Height: 5’8”;

General Appearance: The patient appears healthy but is in mild distress.

Skin: Dry, soft, with no lesions or bruises, no color changes.

HEENT: Atraumatic, normocephalic; PERRLA; EOMs intact. Oral mucosa pink.

Neck: Supple with full range of motion.

Cardiovascular: No murmurs or extra sounds; regular rate and rhythm.

Respiratory: Lungs clear; easy respirations.

Gastrointestinal: Soft abdomen, non-tender; bowel sounds normal.

Musculoskeletal: Crepitus, warm swollen right knee with limited mobility; tenderness on palpation.

Neurological: Erect posture, clear speech; normal gait and balance.

Lab Tests:

• X-ray: Joint space narrowing, subchondral sclerosis, osteophytes.
• ESR and Serum CRP: Normal.
• MRI: Bone marrow lesions, cartilage loss, meniscal tears.

Diagnosis:

Primary Diagnosis: M17.11 - Unilateral Primary Osteoarthritis, right knee. This condition involves the wearing of knee cartilage leading to bone rubbing (Fathi, 2019). Symptoms include swelling, pain, stiffness, and tenderness. The patient's symptoms and tests confirm this diagnosis.

Plan/Therapeutics:

The objective is to relieve pain and restore normalcy. Initial treatment includes topical analgesia paired with non-pharmacological approaches. Capsaicin topical ointment (0.025%) is prescribed for the right knee, applied four times daily. Patient education emphasizes weight loss and physical therapy to strengthen knee muscles.

Return to clinic in 3 months for follow-up.

Evaluation: The patient was cooperative during the assessment, highlighting the importance of thorough history and examinations for accurate diagnosis.

Paper For Above Instructions

Unilateral primary osteoarthritis of the right knee is a common condition, particularly among elderly populations, characterized by degenerative changes in the joint. The pathophysiology primarily involves a gradual degradation of articular cartilage, resulting in bone-on-bone contact, inflammation, pain, and decreased range of motion (Fathi, 2019). A comprehensive SOAP note provides clarity in the patient’s condition, ensuring adequate diagnosis and treatment plans tailored to individual needs.

The presented case reflects a 74-year-old female patient who exhibits significant symptoms attributable to unilateral primary osteoarthritis. The onset of her symptoms approximately seven months ago, alongside reported exacerbation due to weight gain, is consistent with the typical symptomatology of osteoarthritis. Pain rated at 7 out of 10, stiffness after inactivity, and the presence of crepitus upon movement align significantly with osteoarthritic presentations (Fathi, 2019).

The patient’s medical history reveals obesity as a notable risk factor contributing to her osteoarthritis. Obesity is a well-documented risk factor that exacerbates the load and stress on weight-bearing joints, leading to accelerated degeneration (Fathi, 2019; Burmester & Pope, 2017). Understanding the patient’s background and family health history provides essential context, especially noting the prevalence of osteoarthritis and diabetes in her lineage, which could indicate a genetic predisposition to joint diseases.

Physical examination findings noted warmth, swelling, and limited range of motion in the right knee, further confirming the diagnosis of unilateral primary osteoarthritis. Diagnostic imaging, including X-rays and MRIs, play a crucial role in delineating the extent of joint degeneration (Ragab et al., 2017). The identified symptoms, combined with imaging findings of joint space narrowing and osteophyte formation, reinforce the diagnosis of osteoarthritis and differentiate it from conditions like rheumatoid arthritis and gout, which were considered in the differential diagnosis (Sato & Watari, 2020).

In managing her condition, a multi-faceted approach including pharmacological and non-pharmacological treatments is recommended. Topical analgesics like capsaicin have demonstrated efficacy in alleviating localized pain in osteoarthritis (Fathi, 2019). Additionally, encouraging the patient to engage in physical therapy is essential for enhancing joint mobility, reducing stiffness, and improving muscular support around afflicted joints (Cash & Glass, 2017). Comprehensive patient education about weight management and exercise is integral to her treatment plan to mitigate further degeneration and enhance overall function.

Regular follow-up will be necessary to monitor her progress, ensure adherence to treatment, and make necessary adjustments based on her response. With ongoing education and support, the objective remains to maintain or improve quality of life by managing symptoms effectively and promoting active engagement in daily activities.

References

• Burmester, G. R., & Pope, J. E. (2017). Novel treatment strategies in rheumatoid arthritis. The Lancet.
• Fathi, H. M. (2019). Unilateral versus bilateral primary knee osteoarthritis: Relation to the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), C-reactive protein and radiological assessment in Egyptian patients. The Egyptian Rheumatologist.
• Ragab, G., Elshahaly, M., & Bardin, T. (2017). Gout: An old disease in new perspective–A review. Journal of advanced research.
• Sato, M., & Watari, T. (2020). Housemaid’s Knee (Prepatellar Septic Bursitis). Cureus.
• Cash, J. & Glass, C. (2017). Family practice guidelines. New York, NY: Springer.
• Stead, W. (2019). Symptomatic treatment of acute pharyngitis in adults. In L. Kunnis (Ed.). UpToDate.