Lisbely DellaPorta

10/09/2023

SOAP Note 2

Date of Assessment: 10/23/23

Subjective:

ID: Riley Miller

● age 38

● identifies as female, she/her pronouns

● self referred, reliable, alert and oriented X4

Travel/ COVID Screen:

Patient denies travel outside the US or state in the last 3 months. Patient states they
are vaccinated for COVID; last booster administered in September 2023. Will look
into patient’s immunization record to verify. Patient denies being around any COVID
positive individuals and denies testing positive for COVID within the last 10 days.
Patient denies fever, cough, SOB, within the last 10 days.

CC: Patient states "my left knee hurts”.

HPI: Riley Miller is a 38 year old female with no prior history of knee pain or any other
musculoskeletal ailments, injuries, or disease. She states at today's visit that she "has had left
knee pain for almost 2 weeks but has become worse in the last two days”. Patient points to
the left knee when describing where the pain is. Pain is constant. Pain is alleviated when
ibuprofen is taken and ice is applied. Bending the knee, exercise, and ambulating makes the
pain worse. Pain does not radiate. According to the patient, pain occurs at all times. Patient
states pain began around 2 weeks ago after she was chasing her dog and “stepped wrong”.

Pain: 7/10

Medical History: Patient denies any childhood or adult medical history

Hospitalizations: Patient denies any hospitalizations

Surgical History: Patient denies any surgeries

Current Medications: Ibuprofen 600 PO PRN, patient denies any other OTC, herbal or
prescribed medications

Allergies: Medications: None Environmental: None. Food: None

Family History: asked but not pertinent

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10/09/2023
Personal and Social History: pt. States she usually works out 3x a week, mainly does weight
lifting and jogging. Does not drink, states she has a healthy diet, and denies any drug use or
smoking

Sexual/ Contraceptive History: pt. Not sexually active

Immunizations: asked but not pertinent

Health Screenings: Lyme disease screening offered

Even though this is a focused visit, make sure to complete a full Review of Systems!!

Review of Systems:
General: No fever, chills, weight loss, night sweats or fatigue
Psychiatric: No depression, anxiety, hallucinations, voices or suicidal idealizations
Skin, Hair, Nails: Skin: no changes in pigmentation, no changes in texture, no new moles, no
lesions. Hair: no changes in hair texture, no changes in hair thickness, no loss of hair. Nails: not
changes in nail shape, no changes in nail texture, no changes in nail brittleness
HEENT: Head: no recent head injuries, no dizziness, or headaches. Eyes: No vision changes,
discharge, pain or redness from the eyes. Ears: No pain, hearing loss, tinitis or discharge from
ears. Nose: No pain, congestion, or discharge. Throat/Mouth: No sores with the mouth, tooth
pain, or a sore throat.
Neck (lymph, thyroid): No neck stiffness, neck pain, swollen glands or lumps in neck.
Respiratory: No SOB, SOB without exertion, coughing, wheezing, hemoptysis or SOB while
sleeping
Cardiovascular: No irregular heart beat, palpitations, murmurs. Chest pain present as per HPI
Peripheral vascular: No blue or cold tips of fingers or toes, no tingling or numbness in fingers
and toes, or leg cramping
Gastrointestinal: No nausea, vomiting, diarrhea , constipation, bloating, abdominal pain, or blood
in stools
Urinary: No increased urinary frequency, pain with urination, urinary hesitancy, blood in urine,
or flank pain
Genital: No pain, unusual vaginal discharge, unusual smell
Breasts: No changes in breast texture, denies any breast pain, denies any lumps, denies discharge
from nipples
Musculoskeletal: No Hx of any broken bones, weakness, and bony deformities. Does have red
and edematous left knee, refer to HPI
Neurological: No memory loss, slurred speech, gait disturbances, and facial drooping
Hematologic/Endocrine: No increased thirst, increased urination, heat or cold intolerance, No Hx
of blood transfusion, anemia, or easily bruising
Objective: (physical exam findings)
Pain Scale: 7/10
PHQ Score = Not indicated as per pt. Hx
CAGE Score = Not indicated as per pt. Hx
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10/09/2023
General: patient looks well groomed, well nourished, good posture, clean clothes. Appropriate
mood and affect. Able to answer questions appropriately and maintain good eye contact.
Reliable historian. Does have trouble with ambulating due to left knee pain and edema.
Mental Status/Psychiatric: patient is alert and oriented, patient able to follow commands and
cooperative, able to recall recent memory, patient displays appropriate judgment
Skin, Hair, Nails: skin appears dry, smooth, with good turgor, freckles scattered throughout, no
lesions, lumps, or nodules. bruising, edema, and redness to left knee noted. Hair appears full,
think, no bald spots or thinning. Nails are clean, trimmed, and no obvious deformities
HEENT:
Head: Normocephalic, no visible or palpable masses, depressions, or scaring, head appears
symmetrical, temporal artery elastic and non tender, temporomandibular joint palpated with full
range of motion without tenderness
Eyes: PERRLA, visual field full by confrontation, extraocular movements smooth and
symmetric with no nystagmus, eyelids normal position with no abnormal widening or pros is, no
redness, discharge, or crusting noted on lid margins, conjunctiva and sclera appear moist and
smooth. Sclera white with no lesions or redness, no swelling or redness over lacrimal gland.
Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities. Irises are
round, flat, and evenly colored. Pupils converge evenly.
Ears: Ears are equal in size bilaterally. Auricles are aligned with the corner of each eye. Skin
smooth, no lumps, lesions, or nodules. No discharge. Non tender on palpation. No cerumen noted
on the external canal. During whisper test, patient able to repeat 3 word phrase.
Nose: smooth and symmetrical, able to sniff through both nostrils, no nasal deviation, no
drainage notes. Frontal and maxillary sinuses non tender upon palpation
Throat: lips pink, smooth, and without lesions. Buccal mucosa pink, moist, and without
exudates. 32 yellowish teeth noted with a grayish spot on the right front tooth. Gums pink
without redness or swelling. Equal and bilateral strength in tongue. Ventral surface of the tongue,
smooth, moist, and pink. Soft palate and hard palate smooth, moist, and pink.
Neck: No lesions, supple, full range of motion, non tender. Neck is symmetrical with no bulging
masses.
Lymph nodes: non tender, non palpable, and without enlargement
Thyroid: No enlargement, non-tender without any nodules, masses, or goiter
Thorax & Lungs: Clear lung sounds on auscultation and percussion, no adventitious breath
sounds, equilateral anterior and posterior thoracic movement. No retractions or accessory muscle
use. No crepitus, masses, or tenderness upon anterior and posterior chest palpation.
Cardiovascular: Normal S1 and S2. No S3 and S4 or murmurs. Regular heart rate and rhythm.
No bruits on carotid. + 2 pedal pulses and radial pulses. PMI is not visible and is palpable at the
5th intercostal space at the midclavicular line. JVD is 3.
Peripheral Vascular: No peripheral edema, cyanosis, or pallor. Extremities warm and well
perfused. Capillary refill is less than 2 seconds. Peripheral pulses are +2 equal and bilaterally.
Hair is distributed evenly on lower extremities.
Musculoskeletal: Gait impaired due to pain in left knee with weight favoring the right side.
Patient’s left knee appears to be red, swollen, and warm. Left knee does not display any redness,
swelling, or warmth. Discomfort and pain exhibited with light palpation over medial joint of left
knee. Right knee does not exhibit same discomfort. Right knee able to bend and flex with no
signs of distress. Left knee pain occurs with any movement. No crepitus or joint effusion noted.
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Knees are in symmetrical alignment. There is full range of motion in all joints except the left
knee.
There are no signs of any other joint injuries. No muscular atrophy noted.

Assessment:

Identify problems or risks:

Working Diagnosis: Left Knee Pain (M25.562)

Differential Diagnosis: Bursitis, Meniscal Tear, Ligament Tear or Injury, Knee Strain,
Tendonitis

Possible Diagnosis: Knee Strain

Plan: X-rays or knee

CT or MRI if there is suspected soft tissue injury
Rest joint
Knee brace if knee in unstable or there is too much pain with movement
NSAIDs for pain and swelling
Consider physical therapy referral