Soap note

ICD #1 –M25.569 – PAIN IN UNSPECIFIED KNEE
ICD #2 –Z83.2 – FAMILY HISTORY OF DIS OF THE BLD/BLD-FORM ORG/IMMUN MECHNSM
ICD #3 –M05.169 – RHEUMATOID LUNG DISEASE W RHEUMATOID ARTHRITIS OF UNSP KNEE
   
CPT #1 –99244 – OFFICE CONSULTATION, 3 KEY COMPONENTS:COMPREHENSIVE HX; COMPREHENSIVE EXAM; MED DECISION MOD COMPLEX

 

WE’VE HAD A GOOD SUCCESS RATE ON THIS ASSIGNMENT. PLACE THIS ORDER OR A SIMILAR ORDER WITH PapersSpot AND GET AN AMAZING DISCOUNT

CC: bilateral knee pain

 

HPI:

Forty-seven years old female, present complaint  of bilateral knee pain. She states, four days ago, when I was at  works ( ware house manager ) , and she does 12 hours shift,  she feels like something broken in her knees. She took Advil 500 mg; it gets better for only 30 min, and the pain started again.  She had difficulty sleeping for four nights because of the pain, and she rated the pain  8/10. She said rest makes it better and moving  make it worse and also did not go to work for two days, cannot move around the same as before. Redness , stiffness and warmth to touch . the pain is described aching . no back , hip , leg pain . sitting and getting up is painful .

she has a history of anemia, chest pain ( last year), ruhmitoid arthritis (2 years ago)

Anemia is running in her family, heart disease and diabetes

The patient lives with her daughter in a two-bedroom apartment, her daughter in college, and she supported her  financially.

 

Allergies :

NKDA

 

Current Medication :

Advil 200 mg po PRN for pain

Iron 325mg po three times daily

Folic acid 5mg po daily

Norco 5/325  mg  PRN  as needed if the pain is higher than 4/10

 

PM HX :

Bilateral knee Arthritis diagnosis 2 months a go

Hgb 7  01/15/20  hospitalization , blood transfusion

Colonoscopy  10 years ago normal

Immunization up to date

Pap smear  2019  normal

 

Social History :

Divorce on 2000  lives with her daughter ( 25 years old  college student ). No drink or smoke or illegal drug used .

 

Family history :

Parents are alive , dad has heart problem ( CHF) and mom is diabetic

 

 

ROS:

General: female alert and oriented, cooperative, in no acute distress.

CV: No reports of chest pain or palpitations

Respiratory: No reports of shortness of breath or cough

Musculoskeletal: Reports  bilateral knee pain and increased with  mobility

Neuro: No reports of numbness, tingling, but  weakness to extremities

 

WE’VE HAD A GOOD SUCCESS RATE ON THIS ASSIGNMENT. PLACE THIS ORDER OR A SIMILAR ORDER WITH PapersSpot AND GET AN AMAZING DISCOUNT

 

Objective :

Physical Exam:

Vitals: BP 138/ 65; HR 73, regular; RR 18, regular; Hgt 5’ 2”; Wgt 145 lbs., (60kg);

General: No acute distress

HEENT: Eyes – no drainage, sclera white, wears contacts; Ears – TM gray, intact, with light reflex noted, pinna and tragus nontender; Nose –  Nares patent, no drainage; Throat – oropharynx moist, no redness, Dentition good, no cavities or repair; neck supple, anterior and posterior cervical lymph nontender to palpation, no lymphadenopathy, thyroid midline, small and firm, without palpable masses.

Skin: Warm dry and intact, no lesions noted

CV: S1, S2, RRR, no murmurs or rubs

Lungs: Clear to auscultation bilaterally, no labored respirations.

Abdomen: Soft, round, nontender, bowel sounds present, no organomegaly, no abdominal bruits, no costovertebral angle tenderness.

Musculoskeletal:  pain with range of motion to both knees, nontender to palpitation bilaterally, abnormal  gait

Genitourinary: Bladder nontender

 

 

 

 

 

 

 

 

Assessment :

 

Modified diagnostic and impression

 

Assessment of newly developing symptoms

 

Assessment of response to care/treatment

 

Assessment of functional capacity

 

Stats assessments (acute, chronic, recurrent)

Bilateral knee pain ,Anemia , chest pain , RA,

Exam of both knee showed neuro vascular is normal ,  decrease ROM in bilateral knee , palpitation of pedal pulses  is normal .

 

 

Plan :

Diagnostics : CBC, CMP , lipid panel , CRP, ESR, anti-CCP

x-ray of both knee  to rule out fracture or other associated injuries

refill pain medication as needed

refer to physical therapy due to pain and history of RA

Referral to specialist for MRI on both knees  to assess bilateral soft tissue injuries

Return to clinic in 2 weeks for follow up

Return to work  after next follow up   

 

WE’VE HAD A GOOD SUCCESS RATE ON THIS ASSIGNMENT. PLACE THIS ORDER OR A SIMILAR ORDER WITH PapersSpot AND GET AN AMAZING DISCOUNT