Soap Note
Description
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.
Allergies: NKA.
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 patients soap note to include:
Subjective: A thorough review of systems
Objective: A thorough physical examination
Primary diagnosis
3 differential diagnosis with one citation for each ddx (APA formatted).
Laboratory tests
Diagnostic testing
Management plan
Medications
Non-pharmacological approach
Follow up
Patient education and Health promotion
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Must be APA 6th edition format .
References: A minimum of 3 different references are required for this assignment. All references must be properly APA formatted.
Please see attached an example of a soap note .
Plagiarism score should be less than 20 %.
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References:
Nursing Standards
Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Clinical Guidelines
Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
Living Guideline
Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E
Evidence-based practice
BMJ Best Practice
Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/
Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com
Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf
JBI: Evidence summary
Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global
JBI: Best practice information sheet
Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.
Cochrane Database of Systematic Reviews
Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2
Drug Information
Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au
Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm
Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html
Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/
Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html
Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis
Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia
Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367
NCBI Bookshelf
Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/
Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au
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