PRAC 6531 Episodic Visit: Musculoskeletal Focused Soap Note

PRAC 6531 Episodic Visit: Musculoskeletal Focused Soap Note

PRAC 6531 Episodic Visit: Musculoskeletal Focused Soap Note

PRAC 6531 Episodic Visit: Musculoskeletal Focused Soap Note Sample

Episodic/FocusNote Template

Patient Information:

Initials: G.L, Age: 68 years, Sex: Male, Race: White

S.

CC (chief complaint) “Painful knee joint.”

HPI:

G.L. is a 68-year-old White male who came to the office with complaints of painful left knee joint He states that he began experiencing mild knee pain about 15 months ago after walking moderate to long distances. The pain advanced and started occurring when he walked, accompanied by stiffness that limited his movements. The severity of the joint pain has worsened over time from mild to moderate pain. He now experiences joint stiffness in the morning and during rest on some days. He described the pain as deep and achy in the left knee joint, lasting 10-15 minutes. The joint pain is aggravated by activities such as walking and alleviated to some degree by rest and Tylenol, but nothing relieves the joint stiffness. He states that the symptoms are only on the left knee and the right knee is unaffected. He denied using any other medication or measures to relieve the symptoms. He rates the pain at 5/10.

Current Medications:  OTC Tylenol 500 mg PRN.

Allergies: No food or drug allergies.

PMHx: Immunization is up-to-date. No history of chronic illnesses or surgery.

Soc Hx: G.L. is a retired sheriff. He is married and lives with his wife. He has three children who have moved out of the family home and have their families. His hobbies are watching basketball and visiting museums. He has a history of tobacco smoking 2PPD but stopped five years ago after undergoing psychotherapy for nicotine addiction. He drinks beer 4-5 bottles on weekends.

Fam Hx: The paternal grandfather died at 87 years due to prostate cancer. His maternal grandmother had HTN and heart failure. The mother died from a stroke at 84 years. The elder brother has HTN. Children and grandchildren are alive and well.

 ROS:

GENERAL: Reports some weight gain. Denies fever, chills, or increased fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Denies ear pain, discharge, hearing loss, or tinnitus.  Denies mucous discharge, nose bleeding, dental pain, difficulty in swallowing, or voice hoarseness.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies SOB, chest tightness, palpitations, or edema.

RESPIRATORY: Denies SOB, cough, chest tightness, sputum production, or wheezing.

GASTROINTESTINAL: Denies nausea, vomiting, abdominal pain, tarry stools, or bowel changes. 

GENITOURINARY: Denies dysuria, penile discharge, increased urination, or urinary urgency or frequency.

NEUROLOGICAL: Denies headache, paralysis, or tingling sensations

MUSCULOSKELETAL: Reports limitations in movement. Positive for left knee joint pain and stiffness. Denies muscle or back pain.

HEMATOLOGIC: Denies bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes.

PSYCHIATRIC: Denies depression or anxiety symptoms.

ENDOCRINOLOGIC: Denies heat/cold intolerance, acute thirst, or hunger. ALLERGIES: Denies hives or allergies.

O.

Physical exam:

Vital Signs: Temp-98.96; BP- 132/80; HR-78; RR-16; SPO2-99%

Height- 5’5 Weight- 189, BMI-31.4

General: The patient is a 68-year-old White male. He is alert and in no acute distress. He is well-groomed and appropriately dressed. He has a coherent speech and goal-directed speech.

Cardiovascular: Regular heart rate and rhythm. S1 and S2 present.

Respiratory: Smooth respirations with unison chest rise and fall. Lungs clear on auscultation.

Musculoskeletal: ROM-3/5 (left knee joint); Right knee joint- 5/5. Reduced ROM of the left knee joint with crepitus.

Neurological:  Muscle strength 4/5; Stable body balance; CNs are intact.   

Diagnostic results:

Erythrocyte sedimentation rate (ESR) – WNL

C-reactive protein (CRP) – WNL

WBC count- WNL

Rheumatoid factor-Negative

X-ray of the left knee joint – narrowing of joint space.

A.

Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Osteoarthritis: Osteoarthritis (OA) manifests with classic symptoms of deep, achy joint pain worsened by extensive use, swelling, reduced ROM of affected joints, and stiffness during rest (Jang et al., 2021). The patient has deep and achy pain in the left knee joint worsened by use and lasting 10-15 minutes. He also has OA symptoms like joint stiffness, crepitus, and reduced ROM of the affected knee joint. Besides, X-ray findings of narrowed joint space of the left knee joint support OA as the primary diagnosis.

Rheumatoid arthritis (RA): RA is an autoimmune disorder characterized by inflammation of connective tissue in the synovial joint. It presents with joint stiffness with morning stiffness for more than 1 hour, as well as, systemic symptoms such as fatigue, anorexia, weight loss, and low-grade fever (Mohammed et al., 2020).   The patient has knee joint pain and stiffness, making RA a differential diagnosis. However, the patient has no signs of inflammation and the Rheumatoid factor is negative, ruling out RA as the primary diagnosis (Bullock et al., 2018). 

Prepatellar Bursitis: The clinical manifestations of prepatellar bursitis include knee pain, swelling, and redness. There is also difficulty during ambulation, and the inability to kneel on the affected knee (DeBellis et al., 2018). The patient has knee pain and limitations in movement on the left knee, making Prepatellar Bursitis a differential diagnosis.

P.

Therapeutic Interventions: Meloxicam- 7.5 mg PO OD. Meloxicam has been established to be safe and effective in the treatment of OA at doses of 7.5 to 15 mg daily (Hu et al., 2021).

Occupational therapy: A combination of supervised physical exercises and a home exercise program have been found to have the best results (Ebell, 2018).

Heat and cold applications: This was recommended to help in alleviating knee pain.

Education:

Weight loss: Overweight and obesity are risk factors for the development and progression of OA (Lim et al., 2022). Thus, the patient was educated on weight loss interventions including increasing physical activity and lowering caloric intake to promote healthy weight loss.

Referrals: The patient was referred to an Occupational therapist for guidance on joint protection and physical therapy techniques to help him in carrying out activities of daily living (Ebell, 2018).

Follow-up:  A visit was scheduled after four weeks.  

Reflection

The preceptor made an appropriate diagnosis for this patient since he presented with the cardinal symptoms of OA. I learned that OA is a non-inflammatory disease caused by increased pressure on the joints. It is associated with controllable non-biological factors such as overweight/obesity. Health promotion should focus on nutrition to promote weight loss and alleviate OA symptoms by reducing the load on the knee joint (Lim et al., 2022).

References

Bullock, J., Rizvi, S. A. A., Saleh, A. M., Ahmed, S. S., Do, D. P., Ansari, R. A., & Ahmed, J. (2018). Rheumatoid Arthritis: A Brief Overview of the Treatment. Medical Principles and Practice: international journal of the Kuwait University, Health Science Centre, 27(6), 501–507. https://doi.org/10.1159/000493390

DeBellis, N., Cong, G. T., Mikhail, C., & Gladstone, J. (2018). Overuse injuries of the knee. Annals of Joint, 3(3).

Ebell, M. H. (2018). Osteoarthritis: rapid evidence review. American family physician, 97(8), 523-526.

Hu, F., Wu, G., Zhao, Q., & Wu, J. (2021). Evaluation of analgesic effect, joint function recovery and safety of meloxicam in knee osteoarthritis patients who receive total knee arthroplasty: A randomized, controlled, double-blind study. Medicine, 100(35), e26873. https://doi.org/10.1097/MD.0000000000026873

Jang, S., Lee, K., & Ju, J. H. (2021). Recent Updates of Diagnosis, Pathophysiology, and Treatment on Osteoarthritis of the Knee. International journal of molecular sciences, 22(5), 2619. https://doi.org/10.3390/ijms22052619

Lim, Y. Z., Wong, J., Hussain, S. M., Estee, M. M., Zolio, L., Page, M. J., Harrison, C. L., Wluka, A. E., Wang, Y., & Cicuttini, F. M. (2022). Recommendations for weight management in osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis and cartilage open, 4(4), 100298. https://doi.org/10.1016/j.ocarto.2022.100298

Mohammed, A., Alshamarri, T., Adeyeye, T., Lazariu, V., McNutt, L. A., & Carpenter, D. O. (2020). A comparison of risk factors for osteo- and rheumatoid arthritis using NHANES data. Preventive medicine reports, 20, 101242. https://doi.org/10.1016/j.pmedr.2020.101242

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Episodic Visit: Musculoskeletal Focused Note

For this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.

Chapter 174, “Shoulder Dislocations” (pp. 1163–1167)

Chapter 175, “Ankle and Foot Splinting, Casting, and Taping” (pp. 1168–1175)

Chapter 176, “Cast Immobilization and Upper Extremity Splinting” (pp. 1176–1185)

Chapter 177, “Knee Braces” (pp. 1186–1192)

Chapter 178, “Fracture Care” (pp. 1193–1211)

Chapter 180, “Joint and Soft Tissue Aspiration and Injection (Arthrocentesis)” (pp. 1221–1239)

Chapter 181, “Trigger-Point Injection” (pp. 1240–1244)

Chapter 235, “Principles of X-Ray Interpretation” (pp. 1566–1575)

Practicum Resources

HSoft Corporation. (2019). Meditrek: Home.

Links to an external site. https://edu.meditrek.com/Default.html

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.

Walden University Field Experience. (2019a). Field experience: College of Nursing.

Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/home

Walden University Field Experience. (2019b). Student practicum resources: NP student orientation.

Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation

Walden University. (2019). MSN nurse practitioner practicum manual.

Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments

Document: Episodic/Focus Note Template (Word document)

Download Episodic/Focus Note Template (Word document)

To prepare:

Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.

Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:

Assignment:

Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 9.

By Day 7

Submit your Episodic/Focused Note Assignment.

(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 9.)

submission information