History of Present Illness
Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.
History of Present Illness: Mr. Peterson is 52-year-old male construction worker who presents to the clinic with symptoms of right knee pain related to a fall sustained at home one week ago while he was coming down the stairs. Patient states that he tripped and during the fall, the right knee twisted and was caught between two bars of the stair wells. Immediately after the fall, the pain was sharp and stabbing, and he was unable to walk straight and apply weight on the knee. He applied ice and took 800mg of Motrin and went to bed.
Patient states he did not want to go to the emergency department due to the long wait. After 24 hours he applied warm compresses intermittently and took extra strength Tylenol as needed. Mitigating factors include ES Tylenol, heat application, and resting the knee. However, sometimes the pain is so severe that even Tylenol does not help. Aggravating factors are long standing, bending the knee, and climbing stairs. He describes the pain as sharp, and annoying at the same time. At present time he feels like “something is not right inside the knee”. Level of pain is 8/10. He denies previous musculoskeletal injuries. Patient also reports shortness of breath but denies chest pain.
PMH: Asthma, bipolar disorder. Left knee anterior crucial ligament (ACL) 10 years ago from basketball injury.
Past surgical history: Right hip replacement 15 years ago from kick boxing.
Medications/OTC: Theophylline, Prednisone, Singular, Geodon, Prozac, Benadryl, Tylenol as needed.
Allergies: NKA.
Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with diabetes type II.
Health Maintenance: Immunization up to date.
Social history: Patient does not smoke, drink or use recreational drugs. He maintains a regular diet and exercises 3 times a week, has been married for 10 years and lives with his wife and one adult son, and one teenage daughter, is a mathematics teacher in the same high school where he attends clinic. And sleeps well.
With the information provided above, please continue the patient’s soap note to include:
Subjective: A thorough review of systems
Objective: A thorough physical examination
Primary diagnosis: Must be supported by subjective and objective findings.
3 differential diagnoses with one citation for each ddx (APA formatted).
Laboratory tests
Diagnostic testing
Management plan:
Medications
Non-pharmacological approach
Diagnostic (if applicable)
Referral (if applicable)
Follow up
Patient education and Health promotion (disease, lifestyle, medication safety and side
effects…).
References: A minimum of 3 different peer-reviewed references are required for this assignment. All references must be properly APA formatted and published within 5 years.
Note: Please use the FNU soap note template. Review the soap note examples posted on Bb. Also, have the soap note rubric handy when completing your assignment.
Below is how an example of how a reference list looks like:
References
American Lung Association. (2009). Chronic obstructive pulmonary disease (COPD) fact sheet.
Retrieved on March 8, 2013, from http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html
American Lung Association. (2010). The promise of research. Retrieved on March 12, 2013,
from http://www.lung.org/finding-cures/research-news/promise-of-research/por-fall-2010/promise-of-research-fall2010.pdf
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2012). Primary care: a
collaborative practice. St. Louis, Mo.: Elsevier/Mosby.
Durairaj, L. (2010). Disparities in lung disease: Ethnic & racial clues. Retrieved on March 7,
2013, from http://www.lung.org/assets/documents/publications/research-awardsnationwide/RAN0405_LR.pdf
Miravitlles, M. et al. (2010). Cost of chronic bronchitis and copd: 1-year follow-up study.
Retrieved on March 8, 2013, from https://journal.publications.chestnet.org/data/Journals/CHEST/21990/784.pdf
National Guideline Clearinghouse. (2010). Management of uncomplicated acute bronchitis in
adults. Retrieved on March7, 2013, from http://www.lung.org/finding-cures/research-news/promise-of-research/past-issues/por-spr
Niederman, M., S. et al. (2012). Treatment cost of acute exacerbations of chronic bronchitis.
Retrieved on March 11, 2013, http://www.ncbi.nlm.nih.gov/pubmed/10321424
Poole P, H. (2012). Prophylactic antibiotic therapy for chronic bronchitis and chronic
obstructive pulmonary disease (COPD) (Protocol), Retrieved on March 11, 2013, from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764/pdf
South Carolina Department of Health and Environmental Control. (2010). Identification and
elimination of health disparities among populations. Retrieved on March 8, 2013, from http://www.scdhec.gov/health/chcdp/tobacco/goal4.htm
Thomas, M. (2012). Acute bronchitis in adults. Retrieved on March 2, 2013, from
http://www.uptodate.com/contents/acute-bronchitis-in-adults?source=search_result&search=bronchitis&selectedTitle=1%7E150
