To prepare:
Review the Comprehensive SOAP Note Template.
Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding the personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Please write about the patient below with left knee pain
Chief Complaint: “Left knee pain.”Subjective: History of Present Illness:U.N. is a 73-year old male with history of osteoarthritis in bilateral knees who was admitted to the hospital for chronic bilateral knee pain that has not been controlled by previous treatment. Patient is here for an elective left knee replacement. He complains the left knee is worse than the right and that he is having no relief, the pain is travelling into his hip at this time. He states he is unable to care for his wife due to the pain. Mostrecent XRAY shows diagnosis of tricompartmental disease of the left knee. Patient has had no previous surgeries on this knee. Patient complains of aching pain, severity 8/10.
Objective: Vital Signs: T:97.3, HR:57, RR: 18, BP: 101/59, 02: 96% 2 liters NC, Ht: 6’0, Wt: 250, BMI: 33.9
Rheumatoid Arthritis (RA):
