Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.
History of Present Illness: Mr. Brown is 45-year-old male teacher 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 because of 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 standing too long, 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.
Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with DM 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. He has been married for 10 years and lives with his wife and one adult son, and one teenage daughter. He is a mathematics teacher in the same high school where he attends clinic. He 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
3 differential diagnosis with one citation for each ddx (APA formatted).
Patient education and Health promotion
References: A minimum of 3 different references are required for this assignment. All references must be properly APA formatted.
This assignment will be graded according to the rubric. Please have the Rubric handy when you are writing the soap note.