Below is the attached copies of the rubric, school sample and the sample of the soapnote am writing
70 year old female with pain and inflammation in my right knee
TOPIC UNILATERAL PRIMARY OSTEOATHRITIS RIGHT KNEE
please do not add the evaluation of the patient encounter
SOAP Note Week Two
United States University
FNP592: Common Illnesses Across the Lifespan
Dr. Theresa Gress
October 1, 2020
SOAP Note Week Three
ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.
S:
CC: “Cough, runny nose, and sore throat x 7 days”
HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian
PMH:
Allergies: No known drug allergies. Strawberries (rash), seasonal allergies
Childhood: Asthma until high school, chickenpox at age 2
Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)
Medications: None
Vaccinations: received childhood vaccines, Last flu shot given Oct 2019.
Denies psychiatric history.
Social History:
Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink
2 months ago, Engaged, works in IT, Hobbies include archery.
Family History:
Mother died age 60-Diabetes II
Sister 42yo living -HTN
Maternal Grandma died age 67- Dementia
ROS:
General: No weight change, weakness, fatigue, fevers..
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORRHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam was 4 months ago.
C/V: Denies chest pain, palpitations.
Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: No headache, dizziness, focal numbness/weakness, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness.
O:
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8
Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.
HEENT:
Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline.
Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema
1
Soapnote on Unilateral Primary Osteoarthritis, right knee
Student’s Name
Institutional Affiliation
Course Name and Number
Instructor’s Name
Date
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2
Soapnote on Unilateral Primary Osteoarthritis, right knee
Name: Date: Time:
Age: 74 Sex: Female
SUBJECTIVE
CC: “I have pain and inflammation in my right knee.”
HPI: A 74 year old Hispanic female presents to the office with complains of pain and
inflammation on her right knee. The patient states that her symptoms started about 7
months ago and they have been worsening as time goes by. The patient also states that
she has been experiencing loss of flexibility, stiffness, tenderness and grating sensation of
right knee when walking. The patient adds that she noticed her symptoms got worse after
adding five pounds. The patient describes her pain as sharp and rates it as 7/10 and adds
that this condition is making causing her to have limited range of motion. The patient
states that her condition gets worse with activities and goes away when resting. The
patient also reports that she feels stiffness after awakening from rest or in the morning.
The patient reports that she was diagnosed with obesity 2 years ago and she manages her
condition with medication. The patient denies being diagnosed with other chronic
ailments. The patient state that she sometimes takes ibuprofen medication to relieve her
symptoms but the effect of the medication is so small compared to her pain.
Medications:
Ibuprofen (Rx OTC) 300mg PO q6-8hr for pain.
Orlistat (Alli) 60 mg PO q8hr with each fat containing meal for obesity.
PMH
Medication Intolerances: None.
Major traumas: None.
Chronic Illnesses: Obesity
Hospitalizations/Surgeries: None.
This study source was downloaded by 100000783599662 from CourseHero.com on 03-23-2022 04:22:29 GMT -05:00
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https://www.coursehero.com/file/125394821/Soapnote-on-Unilateral-Primary-Osteoarthritis-right-kneedocx/
3
Allergies: No known allergies.
Family History: The patient reports that her father and paternal grandparents had
diabetes and adds that his father was diagnosed with osteoarthritis before dying about 20
years ago. The patient states that her mother died of a road accident but did not have any
underlying health condition. The patient states that he has a daughter and a son and his
son is obese.
Social History: The patient is a retired social worker and she holds a degree in sociology.
The patient is married and lives with her husband in a safe and quiet environment in an
upcountry house. The patient de
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