SOAP Note – Osteoarthritis - Premium Essay Helpers

SOAP Note – Osteoarthritis

ID:

M.W. came to the clinic accompanied by his last born-24-year-old son. He was aware of the settings and reasons for the visit and gave a reliable history of his health and present illness without intervention from his son.

Subjective:

CC: “I came to have this pain I have been having, especially on my knees and around here at the hips.”

HPI:

M.W., a Native Hawaiian 68-year-old male, presents to the clinic accompanied by his 24-year-old son with a complaint of experiencing worsening pain in his knees and around the hips. He reports that he has been experiencing pain in his knees, back, waist, and hips for the last three years. However, the knees and hips have worsened over the last 8 months. The current pain is majorly in his knees and hips and causes constant discomfort, especially at night. The pain has been there for the past year before it got worse, thus the decision to visit the clinic. He reports that he initially viewed the pain as a normal part of aging. However, it has been worsening and is constant and discomforting. The pain worsens when bending, squatting, and or with physical activity. M.W. has been using over-the-counter medications, including paracetamol and diclofenac, combined with light exercises to manage the pain. However, that has recently become less effective in reducing the pain. He further notes that he has recently started experiencing muscle and joint stiffness in the morning after waking up. He rates the pain as an 8/10 and notes that it affects his ability to carry out daily activities, and he must always get assistance to move. M.W. adds that he has always worked in manual settings, including as a lumberjack and construction worker. He also has a history of left knee surgery following an injury and hip bone dislocation. He struggles with weight and has been active to improve his overall health.

Past Medical History:

Medical problem list
Hx of obesity
Hx of joint pain
Hx of dislocated hip joint
Preventative care:
Exercising
Has received all childhood vaccines. However, he has been skeptical about seasonal flu and COVID-19 vaccinations.
Surgeries:
Only reported surgery after having a left knee injured
Hospitalizations:
- No reported history of hospitalization except during his surgery after the injury
LMP, pregnancy status, menopause, etc., for women: N/A

Allergies:

Food, drug, environmental
No known food and drug allergies (NKFDA).
No known or reported environmental allergies; however, he notes that he has become quite sensitive to cold mornings and sneezes a lot.

Medications

Over-the-counter medications for pain management

Paracetamol (Acetaminophen) 500 mg PO PRN (pain)
Diclofenac

Family History:

Father:

Deceased at 78 years
Had a history of Type 2 diabetes mellitus
Had a history of obesity and hyperlipidemia
Had a history of hypertension

Mother:

Deceased at the age of 80 years
Had osteoarthritis
Had a history of obesity and hypertension

Sister:

Aged 63 years old with three children
Has a history of hypertension
Is obese
Has hypercholesterolemia

Brother:

Aged 57 years old with two children
Quite healthy but has started complaining of extreme joint pains
Reported as physically overweight but has been a bodybuilder.

Children:

First-born son:
- Aged 41 years
- Married with 3 children
- Obese but with no other notable medical issues
Second-born son
- Aged 38 years
- Married with 2 children
- Reportedly overweight but appears quite healthy with no notable or reported chronic medical issues
Daughter
- Aged 32 years old
- Married with two children
- Reported to be healthy with no notable medical issues.
Last-born son
- Aged24 years old
- Currently in college
- Appears physically fit and healthy
- Reports no medical issues during his visit to the clinic accompanying his father.

Social History:

-Sexual history and contraception/protection

Reports that despite his age, he still tries to engage in sexual activity. However, he has been having issues for the last 1 year, especially with the joint pain.
Opened up on the fact that he has repeatedly used Sildenafil.
Recently, he has not engaged in any sexual activity
Used to use condoms back in the day but denies using them of late or any other forms of protection during his sexual activities
Reports that he has no history of sexually transmitted infections (STIs) except the few times he got an itch around his pubic area and got checked, and it was nothing serious
Has had multiple relationships and many sexual partners besides his wife
Reports having extramarital affairs, including his current partner

-Chemical history (tobacco/alcohol/drugs)

Denies using any recreational drugs in his entire life.
Denies smoking or taking any tobacco products in any forms
He has smoked marijuana a couple of times after he was advised it would help with his joint pains. He reports he did not go further with it after it made him “see things.”
Denies taking drugs and other illegal substances.
Occasionally takes a beer or two, but he avoids alcohol at all expenses
Denies any family history of drug or substance use.

Other:

Has been on a balanced diet for the longest. He is currently cutting down on his sugar and sodium intake.
Has been physically active for most of his life as a lumberjack and during his work days in the construction industry.
Is currently improving in his physical activity, including attempting to walk daily, but the pain has become a limiting factor.
Lives with his younger son and old wife.
His grandchildren come around during the holidays
Has enough social support from his extended family
Has been functioning independently, but due to experiencing increasing pain, it sometimes becomes difficult to function independently
Has a living will

ROS

Constitutional: Denies fever, chills, fatigue, or unpreceded weight loss. Reports feeling generally well for his age, apart from the joint and back pain.

Eyes: No reported changes in vision or eye movement. No eye pain, redness, or discharge. Had last ophthalmic exam one year ago.

Ears/Nose/Mouth/Throat: No hearing loss, ear pain, or discharge. Denies nasal congestion, sinus pain, sore throat, or mouth sores. No recent dental issues.

Cardiovascular: Denies chest pain, pressure, or swelling in extremities. Regularly experiences palpitations with physical activity. No history of heart disease or previous cardiac events.

Pulmonary: Denies cough, wheezing, shortness of breath, or recent respiratory infections. No history of asthma or COPD.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, and constipation. No changes in bowel movement and habits. Reports normal appetite. No history of gastrointestinal diseases, including GERD.

Genitourinary: Denies dysuria, hematuria, and nocturia. No changes in urinal frequency or urgency, or urine color or smell. No history of kidney stones or prostate problems.

Musculoskeletal: Reports bilateral knee and hip pain with morning stiffness lasting a couple of minutes. Reports decreased mobility during joint stiffness. No joint swelling, redness, or warmth in joints. Denies muscle weakness.

Neurological: Denies dizziness, syncope, or numbness. No tingling or weakness. Normal changes in memory and cognitive function are associated with aging. Reports minor occasional headaches,

Psychiatric: Denies depression or episodes of depressive symptoms, anxiety, mood swings, or sleep disturbances. Reports feeling generally positive about life despite the pain.

Endocrine: Denies any heat or cold intolerance. Changes in skin texture expected with age. No history of endocrine disorders.

Hematologic/Lymphatic: Denies easy bruising, bleeding, or history of anemia. No palpable or swollen lymph nodes. No reported history of blood disorders.

Allergic/Immunologic: No known allergies to food, medications, or environmental factors. Denies recurrent infections or autoimmune conditions. Reports recent sneezing in the morning.

Objective

Vital Signs:

HR: 81 bpm
BP: 129/80 mmHg
Temp: 98.6°F
RR: 17 breaths per minute
SpO2: 98%
Pain: 8/10
Height: 5’11”
Weight: 190 lbs
BMI: 26.5

Labs, radiology, or other pertinent studies:

Recent Complete blood count (CBC) and Comprehensive metabolic panel (CMP) a month ago with normal results
Radiology studies ordered today:
- X-ray of the knees and hips area
- Magnetic resonance imaging (MRI)

Physical Exam:

General: Appears well-nourished for his age, in mild distress due to pain, alert, and oriented to space, time, and place. HR: 81 bpm, BP: 129/80 mmHg, body temp: 98.6°F at room temperature, RR: 17 breaths per minute, SpO2: 98%, pain: 8/10, height: 5’11”, weight: 190 lbs
HEENT: Normocephalic, atraumatic, pupils equal, round, reactive to light and accommodation (PERRLA), no erythema or exudates in throat. No visible or palpable masses, depression, or scarring around the face and throat.
Neck: Supple, no lymphadenopathy, no scaring
Cardiovascular: HR 81 BPM, RRR, no murmurs, no rubs or gallops. Palpitations with physical exertion.
Pulmonary/Respiratory: Clear to auscultation bilaterally, no wheezes or crackles
Abdomen: Soft, non-tender, no hepatosplenomegaly, distended. No palpable masses, normal bowel sounds
Musculoskeletal: The knees are tender on palpation bilaterally, with mild crepitus and decreased range of motion (ROM). The hips are tender on palpation, with reduced ROM. Overall, no swelling, erythema, or warmth is noted. Pain on the back to the touch and minor exertion at the third lumbar spine vertebra (L3) are also present.
Integumentary: Intact, no rashes or lesions
Neurological: CN II-XII is intact, DTRs 2+ bilaterally, strength is 5/5 in the upper and lower extremities, and it is strong for age.
Psychiatric: Normal affect, cooperative, mildly distressed

Assessment

Differentials

1. Osteoarthritis (secondary) of knee and hip: Osteoarthritis is the main diagnosis because the patient presented to the clinic with a chief complaint of experiencing worsening pain in both of his keens and around the hips and reported that the pain he has been having pain in his knees, the back, around his waist, and hip bones. He also reported that he experiences stiff joints occasionally, especially in the morning. Notably, pain is a major symptom of osteoarthritis (Doherty & Abhishek, 2024). OA is also a progressive condition that ranges from an asymptomatic, incidental finding during clinical examination to a disabling disorder that leads to eventual joint failure (Doherty & Abhishek, 2024). These are consistent with OA. The patient is also male, a 68-year-old Native Hawaiian, overweight, and worked mostly in manual settings. Loeser (2024), in a discussion of the pathogenesis of OA, notes that it involves multiple causal processes and risk factors, including biomechanical factors, proinflammatory mediators, and proteases. Age, a family history of the condition, obesity/overweight, and a history of injury are among the major risk factors for OA (Louati & King, 2024).
2. Rheumatoid arthritis: The patient reports stiffness of joints and accompanying joint pain consistent with rheumatoid arthritis. However, it is ruled out due to the absence of major symptoms such as joint warmth, swelling, and other systemic symptoms that are critical in the differential diagnosis of rheumatoid arthritis (Baker, 2024).

Bursitis: This differential is possible due to the repetitive use of the joints. However, it can be ruled out based on its localization at the knees and hips.

Diagnosis

Secondary Osteoarthritis (ICD-10: M17.5/M16.5)

Plan

Diagnostics:

X-rays and MRIs of the knees and the hip joints were ordered today to assess for joint space, the presence of osteophytes, and any other possible degenerative changes.

Treatment:

Currently, the patient will be put on Acetaminophen 500 mg PO every 6 hours as needed for pain, and not more than 3000 mg/day.
Based on the outcomes of the X-rays and MRIs, and if OA is confirmed, current guidelines suggest the use of joint-specific management modalities, including pharmacologic, nonpharmacologic, and surgical options, or a combination of all of the interventions (Deveza, 2024; Deveza & Bennell, 2024).

Education:

Educated patient on the nature of OA and the possible diagnosis to expect
Educated patient on options for pain management.
Encouraged the patient to continue with exercises and focus on the use of low-impact exercises like swimming.
Encouraged patient to focus on the advice from the nutritionist and aim to further reduce his weight

Follow Up:

Patient to visit the clinic in 2 weeks
Referral to a physical therapist for a more tailored exercise and physical activity regime

References

Baker, J. F. (2024, June). Diagnosis and differential diagnosis of rheumatoid arthritis. contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis?search=rheumatoid%20arthritis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Deveza, L. A. (2024, June). Overview of the management of osteoarthritis. https://sso.uptodate.com/contents/overview-of-the-management-of-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Deveza, L. A., & Bennell, K. (2024, June). Management of knee osteoarthritis. https://sso.uptodate.com/contents/management-of-knee-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2

Doherty, M., & Abhishek, A. (2024, July 23). Clinical manifestations and diagnosis of osteoarthritis – UpToDate. contents/clinical-manifestations-and-diagnosis-of-osteoarthritis

Florkow, M. C., Willemsen, K., Mascarenhas, V. V., Oei, E. H. G., van Stralen, M., & Seevinck, P. R. (2022). Magnetic resonance imaging versus computed tomography for three-dimensional bone imaging of musculoskeletal pathologies: A review. Journal of Magnetic Resonance Imaging, 56(1), 11–34. https://doi.org/10.1002/JMRI.28067

Loeser, R. F. (2024, June). Pathogenesis of osteoarthritis. https://sso.uptodate.com/contents/pathogenesis-of-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=5%7E150&usage_type=default&display_rank=5

Louati, K., & King, L. (2024, June). Comorbidities that impact management of osteoarthritis. https://sso.uptodate.com/contents/comorbidities-that-impact-management-of-osteoarthritis?search=Osteoarthritis+%28OA%29&source=search_result&selectedTitle=8%7E150&usage_type=default&display_rank=8

Pei, Y., Yang, W., Wei, S., Cai, R., Li, J., Guo, S., Li, Q., Wang, J., & Li, X. (2021). Automated measurement of hip–knee–ankle angle on the unilateral lower limb X-rays using deep learning. Physical and Engineering Sciences in Medicine, 44(1), 53–62. https://doi.org/10.1007/S13246-020-00951-7/FIGURES/9

Uchima, O., Wu, Y. Y., Browne, C., & Braun, K. L. (2019). Peer reviewed: Disparities in diabetes prevalence among Native Hawaiians/other Pacific Islanders and Asians in Hawaii. Preventing Chronic Disease, 16(2), 180187. https://doi.org/10.5888/PCD16.180187

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SOAP Note – Osteoarthritis

Create a pretend SOAP NOTE a geriatric patient 68 years old with OSTEOARTHRITIS

This is a FOCUS SOAP NOTE on OSTEOARTHRITIS so please only include what is pertinent on ROS and Physical exam base on the complaint. you can use our SOAP NOTE TEMPLATE
On the Assessment part put rationale why it is your main diagnosis and also rationales for the two differentials on why it is not the main diagnosis.

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