SOAP NOTE (Musculoskeletal/Orthopedic)

Patient Demographic Data

Name: A.B. Age: 66 years Sex: Female Ethnicity: Sindhi MR#

Subjective
Chief Complaint: Left Knee Pain

History of presenting complaint: A.B. is a 66-year-old female, who presented with a

complaint of left knee pain. It was constant at 5 out of 10 but exacerbated at 7/10 with setting
and movement. It was initiated 6 months ago but became more severe last week. It felt like
cramps. It was not radiating anywhere in the body. The onset was gradual, Patient did not try
any medication to relieve it. However, the patient reports a reduction in pain intensity with rest.

Allergies: No known drug and food allergy.

Current medications:
 Ascard 75mg once daily
 calcium and Vit D 600mg 1 tab PO once a day
 Celbex 200mg twice daily
 Concor 5mg daily.

Past Medical History:

Immunizations: All childhood immunizations, and

COVID-19 vaccination completed.

No surgeries or hospitalizations.
 HTN since 2 years well controlled with medication.
Social History: Denies smoking, alcohol, or substance use. Lives in a nuclear family with
husband and son. Unemployed. Living in own house.
Family History: No family history of any comorbidities.

Review of Systems [ROS]:

General: The patient denies fever, fatigue, insomnia, or weight loss.
HEENT: Denies headaches, injuries or trauma. Denies visual changes or drainage. Denies
earache, drainage, or hearing loss. Denies nosebleeds or nasal congestion. Denies mouth sores or
bleeding in gums. Denies sore throat or swallowing problems.
Respiratory System: Denies SOB, coughing or wheezing.
Cardiovascular: Denise any chest pain or abnormalities of the chest. Denies orthopnea or
palpitations.
Gastrointestinal: denies NV and constipation.
Neurological: Denies anxiousness or memory loss.
Musculoskeletal: Reports limitation in ROM. Denies inflammation but has tenderness. Denies
injuries, trauma, or fractures. Have joint pain in the left knee.
Hematology: Denies bleeding in urine or stool. Denies any bruises.

Psychological: Denies sleeping disturbance. Denies mood disorders or suicidal thoughts.

Objective

General: Temp: 36.6C HR: 55/min, RR: 17/min, BP: 140/70mmhg, WT: 77kg:
HT: 160cm

HEENT: No head injuries or trauma. No earache, drainage, or trauma. No visual changes. Sclera
white.

SKIN: Warm to touch. No rashes, petechiae or bruises. No scars or open wounds.

CV: S1 and S2. Murmurs sound audible.

RESP: Lung sounds clear. No SOB, coughing or wheezing.

GI: Normal bowel sound X4 quads.

MUS: decreased ROM in left Knee. Muscle strength 3/5

Diagnostic tests: Knee X-ray, Bone Dexa Scan, CBC

Differential Diagnosis

1. Osteoarthritis (OA):

The gradual onset of left knee pain over six months is consistent with OA, which typically develops
slowly over time. The exacerbation of pain with movement and sitting is characteristic of OA, as
mechanical stress worsens symptoms. The reduction in pain intensity with rest is also in line with OA, as
symptoms often improve with rest.
2. Rheumatoid Arthritis (RA):

While RA usually affects multiple joints, it can initially be present in a single joint, such as the knee.
The complaint of left knee pain, especially if associated with stiffness and swelling, could indicate RA.
The patient's age (66 years old) is within the range where RA commonly manifests.
3. Osteopenia:

Osteopenia is a condition characterized by reduced bone density, which can predispose individuals to
fractures and joint pain. While osteopenia itself may not directly cause knee pain, it can contribute to
conditions like OA, where joint degeneration occurs due to weakened bones. Osteopenia may be
considered as a contributing factor to the development or progression of OA in this scenario.
Treatment Plan

The plan of treatment will involve immediate relief of pain and multivitamins, especially
Vitamin D and Calcium.
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