Episodic/Focused SOAP Note for Knee Pain

Patient Information: Case #3.

Patient Initials: T.P                 Age: 15           Gender: Male.

SUBJECTIVE: 

Chief Complaint (CC): Knee Pain

History of Present Illness (HPI): The patient who initials is T.P is a 15-year hold make that was presented to the clinic, reports that the pain he feels in one and at times both of his knees started 5 days ago. T.P also informs that he will always experience a catching sensation whenever one or both of this knees click, the catching sensation is felt under the patella. T.P also informs that the pain does not go away immediately, and whenever he stands for quite some time, it makes the pain even worse.  Also, T.P reported that he is often feeling a constant form of pain, and prolonged running or standing will also make it worse. T.P also informed the clinician that he once twisted his knees while he was playing football five days ago.  Also, the patient stated that the has not been able to play with his hockey team due to the pain he feels. T.P also reports that since the injury he has been forced to wear a knee bracelet whenever the pain becomes unbearable. At times the patient reports he has had to use painkillers like ibuprofen, which unfortunately only drives the pain away temporarily. T.P reports that to a scale of 1-10 the pain level is at 6/10

Medications: Patient takes daily Multivitamin

Allergies: Penicillin.

Past Medical History (PMH): Patient reports seasonal allergies.

Past Surgical History (PSH): None.

Immunization History: Flu shot which was received this season.

Significant Family History: Patient reports that his maternal grandmother suffers from osteoarthritis.

SOCIAL HISTORY: Patient has been able to attend school regularly, he also plays hockey with his high school team. Patient does not smoke, does not take alcohol and does not partake any illicit drug.

REVIEW OF SYSTEMS:  

General: No Chills, fever or report of fatigue.

Neck: No injury, pain or history of disc compression or disc disease.

Musculoskeletal: No evidence of arthritis, gout.  Patient reports limited range of motion through the affected knees. Patient has not history of fractures or trauma.

Allergic/Immunologic: Seasonal allergic rhinitis.

OBJECTIVE

PHYSICAL EXAM:

Vita/l signs: B/P — 110/64, P — 75, T — 97.8, RR — 20, Wt — 166 lbs., Ht — 5’10”, BMI — 23.7.

General: The patient is very oriented and Alert x4, there is no evidence of distress.

Neck: No Pain, No JVD present, trauma, rigidity or injury. Trachea is midline. Patient exhibits normal range of motion.

Musculoskeletal: There is evidence of symmetric muscle development, the muscle strengths 5/5 all groups. Patient’s knees appear swollen, they are also tender to touch. Limited range of motion in both knees. There is an audible click heard when patient performs the McMurray maneuver.

Neuro: CNII-XII grossly intact, deep tendon reflexes intact.

Diagnostic tests: ESR, CBC, MRI, Radiography.

ASSESSMENT

Differential Diagnosis:                            

Patellar Tendinitis (jumpers’ knee)

Osteoarthritis

Medial Meniscus Tear

ACL tear

Medial Collateral Ligament Sprain

ORDER  Focused SOAP Note for Knee Pain HERE

Justification of Diagnostic Tests and Differential Diagnosis

People of an adolescent age they are usually very playful and will engage in various sports that would easily result to conditions such as the Knee pain injury. The diagnostic tests are important as they ensure that there is accuracy in the Knee pain diagnosis including ESR and CBC, MRI and Radiography. In this case, a CBC is important as it is going to reveal whether there is presence of anemia, which would mean the patient suffers from a chronic condition. It would also reveal various alterations to White Blood cell count that could also indicate the patient is undergoing an infectious process or presence of leukemia(Sodhi et al., 2017). Also, by conducting an ESR it will indicate that there is evidence of inflammation, which is through a nonspecific test, also the patient can be taken through radiography which is conducted as a way of visualizing the joint thus being able to rule out other reason for pain.  The MRI scans will be done to ensure deeper view of the soft tissues especially in the knee joint thus ensuring the determination of severity and location of the tear if present.

Based on the assessment, the primary diagnosis for the patient is going to be Medial Meniscus Tear.  Injuries related to the Medial Meniscus often occur due to a twisting injury to the knee.  The tenderness, swelling, clicking and catching in the joint all represent a medial meniscus that is often confirmed through McMurray Maneuver.  He second diagnosis the Patellar Tendinitis also known as the Jumper’s Kneed is found in athletes that constantly place pressure towards their knees by running or jumping, which is popular in games like basketball or hockey, and will depict a dull and itchy pain, the patient will also experience a popping and clicking in the joint. In Osteoarthritis, the patient depicts joint inflammation which leads to the osteophyte development and the synovial inflammation which is also characterized by pain, joint stiffness and limited level of motion. At the same time an ACL tear is bound to occur when the knee is hyper extended and twisted.  The symptoms of an ACL tear will often entail a severe level of pain, a popping sensation in the swelling, knee or loss of motion range. The patient will be unstable and the weight will be unbearable.

References

Sodhi, N., Khlopas, A., Newman, J., & Mont, M. (2017). Sources and management of knee pain. The Journal of Knee Surgery, 30(07), 617–617. https://doi.org/10.1055/s-0037-1606259

Werner, S. (2011). Non-operative treatment of athletes with anterior knee pain: Science, classical, and new ideas. In Anterior knee pain and patellar instability (pp. 171–190). Springer London. https://doi.org/10.1007/978-0-85729-507-1_12