Hi. This is a musculoskeletal SOAP note. The instructor is asking…
Question Answered step-by-step Hi. This is a musculoskeletal SOAP note. The instructor is asking… Hi. This is a musculoskeletal SOAP note. The instructor is asking for two specific physical exam in this case. What else would you recommend? The patient experienced a leg injury seven years ago.History of Present Illness (HPI): Mrs. M.J is a 52-year-old white female who presents with acute, stiff, achy, right knee pain (all around her knee), 8/10 in severity, radiating down to her ankle that began 2 years ago, but it has been increasing over time. The knee swells and a warm sensation is felt when she is moving around for more than two hours. The knee pain is constant worsening with movement like walking and physical workout, stress, and cold wheather and it is slightly relief when she is at rest. In addition, she reports knee stiffness and weakness in the morning when she wakes up lasting for about 20 – 30 minutes. She also reports that her knee makes a grinding or cruching sound with movement. The patient is taking Ibuprofen 400 mg by mouth each morning to relief her knee pain with no success. She states that she needs something stronger than what she is currently taking.Physical exam:Musculoskeletal: The right knee exhibit crepitus, a grinding or crackling noise or sensation felt over the joint. There is evidence of a small effusion (fluid) in the right knee. The bone of the knee is slightly enlarged. The medial joint line of the right knee is tender upon palpation. She has limited range of motion in her righ knee, it can only be flexed to 90 degrees. She can not completely straighten her right knee. Her ability to flex and extend at the hips is also diminished slightly; however, she has normal stabily. The patient is unable to cooperate with the test strength due to her knee pain. She is not able to rise from a chair without using upper extremities for push and support suggesting week quadracepts. Health Science Science Nursing NRNP 6531 Share QuestionEmailCopy link Comments (0)
