Site icon Eminence Papers

SOAP Note – Osteoarthritis

Moses

SOAP Note – Osteoarthritis

ID:

Client’s Initials*: M.W. | Age: 68 | Race: Native Hawaiian | Gender: Male | Date of Birth: 01/1/1956 | Insurance: _______ | Marital Status: Married

M.W. came to the clinic accompanied by his last born-24-year-old son. He was aware of the settings and reasons for the visit and gave a reliable history of his health and present illness without intervention from his son.

 Subjective:

 CC: “I came to have this pain I have been having, especially on my knees and around here at the hips.”

HPI:

M.W., a Native Hawaiian 68-year-old male, presents to the clinic accompanied by his 24-year-old son with a complaint of experiencing worsening pain in his knees and around the hips. He reports that he has been experiencing pain in his knees, back, waist, and hips for the last three years. However, the knees and hips have worsened over the last 8 months. The current pain is majorly in his knees and hips and causes constant discomfort, especially at night. The pain has been there for the past year before it got worse, thus the decision to visit the clinic. He reports that he initially viewed the pain as a normal part of aging. However, it has been worsening and is constant and discomforting. The pain worsens when bending, squatting, and or with physical activity. M.W. has been using over-the-counter medications, including paracetamol and diclofenac, combined with light exercises to manage the pain. However, that has recently become less effective in reducing the pain. He further notes that he has recently started experiencing muscle and joint stiffness in the morning after waking up. He rates the pain as an 8/10 and notes that it affects his ability to carry out daily activities, and he must always get assistance to move. M.W. adds that he has always worked in manual settings, including as a lumberjack and construction worker. He also has a history of left knee surgery following an injury and hip bone dislocation. He struggles with weight and has been active to improve his overall health.

Past Medical History:

Allergies:

Medications

Over-the-counter medications for pain management

Family History:

Father:

Mother:

Sister:

Brother:

Children:

Social History:

-Sexual history and contraception/protection

              -Chemical history (tobacco/alcohol/drugs)

Other:

 ROS

Constitutional: Denies fever, chills, fatigue, or unpreceded weight loss. Reports feeling generally well for his age, apart from the joint and back pain.

Eyes: No reported changes in vision or eye movement. No eye pain, redness, or discharge. Had last ophthalmic exam one year ago.

Ears/Nose/Mouth/Throat: No hearing loss, ear pain, or discharge. Denies nasal congestion, sinus pain, sore throat, or mouth sores. No recent dental issues.

Cardiovascular: Denies chest pain, pressure, or swelling in extremities. Regularly experiences palpitations with physical activity. No history of heart disease or previous cardiac events.

Pulmonary: Denies cough, wheezing, shortness of breath, or recent respiratory infections. No history of asthma or COPD.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, and constipation. No changes in bowel movement and habits. Reports normal appetite. No history of gastrointestinal diseases, including GERD.

Genitourinary: Denies dysuria, hematuria, and nocturia. No changes in urinal frequency or urgency, or urine color or smell. No history of kidney stones or prostate problems.

Musculoskeletal: Reports bilateral knee and hip pain with morning stiffness lasting a couple of minutes. Reports decreased mobility during joint stiffness. No joint swelling, redness, or warmth in joints. Denies muscle weakness.

Neurological: Denies dizziness, syncope, or numbness. No tingling or weakness. Normal changes in memory and cognitive function are associated with aging. Reports minor occasional headaches,

Psychiatric: Denies depression or episodes of depressive symptoms, anxiety, mood swings, or sleep disturbances. Reports feeling generally positive about life despite the pain.

Endocrine: Denies any heat or cold intolerance. Changes in skin texture expected with age. No history of endocrine disorders.

Hematologic/Lymphatic: Denies easy bruising, bleeding, or history of anemia. No palpable or swollen lymph nodes. No reported history of blood disorders.

Allergic/Immunologic: No known allergies to food, medications, or environmental factors. Denies recurrent infections or autoimmune conditions. Reports recent sneezing in the morning.

Objective

 Vital Signs:

Labs, radiology, or other pertinent studies:

Physical Exam:

 Assessment

Differentials

    1. Osteoarthritis (secondary) of knee and hip: Osteoarthritis is the main diagnosis because the patient presented to the clinic with a chief complaint of experiencing worsening pain in both of his keens and around the hips and reported that the pain he has been having pain in his knees, the back, around his waist, and hip bones. He also reported that he experiences stiff joints occasionally, especially in the morning. Notably, pain is a major symptom of osteoarthritis (Doherty & Abhishek, 2024). OA is also a progressive condition that ranges from an asymptomatic, incidental finding during clinical examination to a disabling disorder that leads to eventual joint failure (Doherty & Abhishek, 2024). These are consistent with OA. The patient is also male, a 68-year-old Native Hawaiian, overweight, and worked mostly in manual settings. Loeser (2024), in a discussion of the pathogenesis of OA, notes that it involves multiple causal processes and risk factors, including biomechanical factors, proinflammatory mediators, and proteases. Age, a family history of the condition, obesity/overweight, and a history of injury are among the major risk factors for OA (Louati & King, 2024).
    2. Rheumatoid arthritis: The patient reports stiffness of joints and accompanying joint pain consistent with rheumatoid arthritis. However, it is ruled out due to the absence of major symptoms such as joint warmth, swelling, and other systemic symptoms that are critical in the differential diagnosis of rheumatoid arthritis (Baker, 2024).
  1. Bursitis: This differential is possible due to the repetitive use of the joints. However, it can be ruled out based on its localization at the knees and hips.

Diagnosis

  1. Secondary Osteoarthritis (ICD-10: M17.5/M16.5)

 Plan

 Diagnostics:

Treatment:

Education:

Follow Up:

References

Baker, J. F. (2024, June). Diagnosis and differential diagnosis of rheumatoid arthritis. https://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis?search=rheumatoid%20arthritis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Deveza, L. A. (2024, June). Overview of the management of osteoarthritis. https://sso.uptodate.com/contents/overview-of-the-management-of-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Deveza, L. A., & Bennell, K. (2024, June). Management of knee osteoarthritis. https://sso.uptodate.com/contents/management-of-knee-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2

Doherty, M., & Abhishek, A. (2024, July 23). Clinical manifestations and diagnosis of osteoarthritis – UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-osteoarthritis

Florkow, M. C., Willemsen, K., Mascarenhas, V. V., Oei, E. H. G., van Stralen, M., & Seevinck, P. R. (2022). Magnetic resonance imaging versus computed tomography for three-dimensional bone imaging of musculoskeletal pathologies: A review. Journal of Magnetic Resonance Imaging, 56(1), 11–34. https://doi.org/10.1002/JMRI.28067

Loeser, R. F. (2024, June). Pathogenesis of osteoarthritis. https://sso.uptodate.com/contents/pathogenesis-of-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=5%7E150&usage_type=default&display_rank=5

Louati, K., & King, L. (2024, June). Comorbidities that impact management of osteoarthritis. https://sso.uptodate.com/contents/comorbidities-that-impact-management-of-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=8%7E150&usage_type=default&display_rank=8

Pei, Y., Yang, W., Wei, S., Cai, R., Li, J., Guo, S., Li, Q., Wang, J., & Li, X. (2021). Automated measurement of hip–knee–ankle angle on the unilateral lower limb X-rays using deep learning. Physical and Engineering Sciences in Medicine, 44(1), 53–62. https://doi.org/10.1007/S13246-020-00951-7/FIGURES/9

Uchima, O., Wu, Y. Y., Browne, C., & Braun, K. L. (2019). Peer reviewed: Disparities in diabetes prevalence among Native Hawaiians/other Pacific Islanders and Asians in Hawaii. Preventing Chronic Disease, 16(2), 180187. https://doi.org/10.5888/PCD16.180187

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

Question 

SOAP Note - Osteoarthritis

SOAP Note – Osteoarthritis

Create a pretend SOAP NOTE a geriatric patient 68 years old with OSTEOARTHRITIS

This is a FOCUS SOAP NOTE on OSTEOARTHRITIS so please only include what is pertinent on ROS and Physical exam base on the complaint. you can use our SOAP NOTE TEMPLATE
On the Assessment part put rationale why it is your main diagnosis and also rationales for the two differentials on why it is not the main diagnosis.

Exit mobile version