week 8 soap note knee assessment€¦ · week 8 soap note knee assessment 5 neck: neck is supple,...

Running head: WEEK 8 SOAP NOTE KNEE ASSESSMENT 1

Week 8 SOAP Note Knee Assessment

Student’s Name:

Institutional Affiliation:

WEEK 8 SOAP NOTE KNEE ASSESSMENT 2

NURS 6531 Week 8 SOAP Note #3

Patient Information:

A 60-year-old African-American male.

SUBJECTIVE:

Chief Complaint (CC): The patient complained of bilateral knee pain, has rheumatoid nodules in

the hands, elbows, knees, and ankles.

HPI: A 60-year-old African –American with a history of rheumatoid arthritis presents to the

clinic with bilateral knee pain. He has rheumatoid nodules to the hands, elbows, knees, and

ankles that have caused deformities. The pain gets worse with weight-bearing and movement. He

is scheduled for a total knee revision to the right knee later this month. He has had a total knee

replacement in the right knee, and it became infectious. Currently, that knee has been removed,

the bone scraped, and metal rods are attached to the bone. The patient is wearing a custom made

brace using a walker until surgery date. He has currently taken off all rheumatoid arthritis drugs

because they comprise the immune system.

Medications: Flomax 0.4MG Cap in the AM.

Tramadol HCI 50 MG 1 tab Q8hrs PRN pain.

Flonase 50 MCG/ACT 1 spray each nostril every day

Mucinex Extended-Release 12 hour 600 MG 1 tab every 12 hours PRN for 14days.


Allergies: Sulfa and Methotrexate.

PMH: Rheumatoid arthritis, sinusitis, Herpes simplex, benign prostatic hyperplasia.

PSH: Has had a total knee replacement in the right knee. Left hip replacement.

FH: Mother and father are both deceased. Mother had rheumatoid arthritis.

SH: A member of the Baptist faith, lives alone, and very independent. He has adult children who

check on him daily. He smokes a pack a day. Does not drink or take any illegal or street drugs.

ROS

General: Complains of pain in the knees.

HEENT: No reported head injury, lightheadedness, vision changes, hearing problems, abnormal

discharge in the ears. Does not report any nosebleed or nose blockage. Does not state any dental

problems.

Skin: No reported rashes or itching.

Respiratory: No reported respiratory complications.

Cardiovascular: No reported chest pain, or palpitations.

Gastrointestinal: No reported abdominal pain, nausea, or vomiting.

Urinary: No reported urinary changes or difficulty urinating.

Genital/Reproductive: Patient is currently not sexually active.


Neurological: Does not report dizziness, headache, numbness, or tingling in the extremities.

Musculoskeletal: Redness and swelling in both knees. Complains of pain in both knees.

Hematologic: Does not report any history of anemia or bleeding disorder.

Psychiatric: Sometimes gets anxious. Has never had a serious psychiatric disorder.

Endocrinologic: No reported heat or cold intolerance.

OBJECTIVE:

Vitals:

Blood Pressure: 128/84

Heart Rate: 92

Temperature: 97.4F

Respiration: 22

Oxygen Stat: 98% on Room Air

BMI: 18.13

Physical Exam:

General: In no acute distress, well developed, well-nourished.

Head: Normocephalic

Eyes: Pupils equal, round, reactive to light, and accommodation.

Ears: Within normal limits.

Throat: Is clear


NECK: Neck is supple, full range of motion, no cervical lymphadenopathy.

Lymph nodes: No palpable adenopathy.

Skin: No suspicious lesions, warm and dry.

Heart: Regular heart rate and rhythm of 92 BOM, S1, S2 normal.

Abdomen: Flat, normal bowel sounds, soft, and non-tender.

Back: Within normal limits.

Musculoskeletal: Rheumatoid nodules ad deformities on the elbows, knees, and ankles. Right

leg in a custom soft straight cast.

Extremities: 1+ ankles bilaterally.

Neurological: Non-focal.

Psychiatric: Alert, oriented, cooperative with the exam.

Diagnostic Test:

Knee examination. A physical knee exam is performed to check for swelling, redness, and

warmth (Davies & Malone, 2017). The physician also checks for reflexes and muscle strength

during the exam (Davies & Malone, 2017). A knee examination helps the physician to assess for

conditions such as rheumatoid arthritis knee injuries (Davies & Malone, 2017).

Knee X-ray. A knee joint X-ray can be used to assess conditions such as osteoarthritis, detect or

exclude a fracture, and examine tendon or ligament injuries (Davies & Malone, 2017). The


procedure involves imaging the knee in at least two directions (Davies & Malone, 2017). The

examination produces an anterior-posterior image and a lateral image (Davies & Malone, 2017).

Blood tests. A blood test can be used to examine conditions such as rheumatoid arthritis (Davies

& Malone, 2017). Rheumatoid arthritis causes an increased erythrocyte sedimentation rate (sed

rate). A blood test that shows an increase in sed rate is, therefore, an indicator of rheumatoid

arthritis (Davies & Malone, 2017). A blood test may also check for the presence of C-reactive

protein (CRP), which indicates the presence of inflammatory disease (Davies & Malone, 2017).

Blood tests may also look for rheumatoid factor in the blood (Davies & Malone, 2017).

MRI.A procedure that uses a magnetic field and radio waves to create images that can reveal

knee injuries or assess the severity of diseases such as osteoarthritis and rheumatoid arthritis

(Davies & Malone, 2017).

Joint fluid analysis. This is a procedure used to test fluids removed from the knee joints (Davies

& Malone, 2017). The physician administers local anesthesia and uses a needle to draw fluid


from the joints (Davies & Malone, 2017). The obtained fluid is then sent to the lab to test for

conditions such as gout, osteoarthritis, or other joint infections (Davies & Malone, 2017).

Arthrography. A type of imaging test used to assess the knee joints ( Davies & Malone, 2017).A

long, thin needle is used to insert contrast dye in the joint, and a series of X-rays are taken with

the knee in various positions ( Davies & Malone, 2017). It is used to assess tears in the ligaments

or tendons, check for loose bodies or knee dislocation (Davies & Malone, 2017).

ASSESSMENT:

Primary Diagnosis:

Rheumatoid arthritis. Rheumatoid arthritis is a chronic and progressive condition that affects the

immune system (Firestein, 2017). It leads to inflammation, pain in and around the joints, and

swelling in the affected joints (Firestein, 2017). Rheumatoid arthritis usually occurs when the

immune system mistakes the body tissues for foreign substances (Firestein, 2017). When the

immune system responds, inflammation occurs in the target tissues and organs (Firestein, 2017).


It usually starts in the hands and feet but can affect any joint. It may also affect the lungs, eyes,

and heart (Firestein, 2017).

The common symptoms of rheumatoid arthritis include pain and swelling in the affected joints,

stiffness, joint deformity, unsteadiness when walking, fever, loss of mobility, weight loss,

weakness, and nodules in the affected joints (Firestein, 2017). There are no known reasons for a

malfunction in the immune system (Firestein, 2017). Some people may have a genetic

predisposition while others are suspected of developing rheumatoid arthritis due to virus or

bacteria that activates the disease in those who have the inclination (Firestein, 2017). In

rheumatoid arthritis, the immune system attacks the synovium resulting in pain and inflammation

(Firestein, 2017). The synovium is a smooth lining that covers the body’s joints (Firestein, 2017).

Inflammation causes the synovium to thicken, which, if left untreated, destroys the cartilage

(Firestein, 2017). The cartilage is a protective tissue at the end of bones. An inflammation may

also weaken and stretch ligaments and tendons holding the joints together (Firestein, 2017). The

joints will eventually lose their shape and configuration (Firestein, 2017).


The risk factors for rheumatoid arthritis include being sixty years and above, having a family

history of rheumatoid arthritis, obesity, and smoking tobacco (Firestein, 2017). The patient, in

this case, is most likely suffering from bilateral knee pain because of the preexisting rheumatoid

arthritis. The patient states that he has quit his medication because they comprise the immune

system. Stopping the drugs could be the reason for the pain.

Differential Diagnosis:

Osteoarthritis. This is a form of arthritis that occurs when the protective cartilage that cushions

the bones wears down (Felson, 2016). It commonly affects joints in the hands, knees, hips, and

spine (Felson, 2016). Symptoms include pain in the affected joints. The pain may increase during

movement or when carrying weights (Felson, 2016). Other symptoms include joint stiffness,

which is usually noticed upon awakening or after periods of inactivity, joint tenderness, a grating

sensation, nodules, and swelling in the affected joints (Felson, 2016). Osteoarthritis occurs when

the cartilages attached to the bones wear out (Felson, 2016). Cartilages are firm, slippery tissues

that reduce friction during joint motion (Felson, 2016). If the cartilages wear out, the bones will

rub on each other (Felson, 2016). Besides the wearing down of cartilages, osteoarthritis may also

affect the entire joint (Felson, 2016). It can cause bone deformity and deterioration of the


connective tissues holding the joints together (Felson, 2016). It also leads to inflammation of the

joint lining (Felson, 2016). The risk factors include old age, obesity, joint injuries, genetics, and

repeated stress on the joint (Felson,2016). Repeated stress is usually common in sports (Felson,

2016). The patient could be having osteoarthritis because he had symptoms such as knee pain,

which got worse during movement or weight-bearing. However, the symptoms are not enough to

confirm the diagnosis, and further physical examinations and laboratory tests are needed for

confirmation.

Gout. A type of arthritis characterized by sudden severe attacks of pain, swelling, redness, and

tenderness in the joints (Jackson, Malley, & Kroenke, 2016). A gout attack can occur suddenly

and may hinder mobility as it progresses (Jackson et al., 2016). It occurs urate crystals

accumulate in the joints, causing inflammation and extreme pain (Jackson et al., 2016). Urate

crystals form when a person has high levels of acid in the body (Jackson et al., 2016). The body

process uric acid to break down purine (Jackson et al., 2016). Purines are substances that occur

naturally in food and are found in a higher percentage in foods such as meat and seafood,

alcoholic drinks, and drinks sweetened with sugar (Jackson et al., 2016). Increased purine levels


cause the kidney to release excess uric acid, which can build up to create urate crystals in joints

(Jackson et al., 2016). Urate crystals cause pain, inflammation, and swelling. The risk factors for

gout include diet and obesity (Jackson et al., 2016). Eating foods rich in meat and seafood and

soft drinks increase the levels of uric acid, which raises the risk of gout (Jackson et al., 2016).

Being overweight also causes the production of excess uric acid (Jackson et al., 2016). Medical

conditions, such as diabetes and hypertension, may also increase the risk of gout (Jackson et al.,

2016). Genetics and the consumption of drugs such as thiazide diuretics may also increase the

risk of gout (Jackson et al., 2016). The patient, in this case, could be having knee pain causes by

gout that attacked the knee joints. However, further laboratory diagnosis and physical exams are

needed to confirm the diagnosis.

Fractures. The bones in the knee may break if they receive a direct blow to the bones (Jackson et

al., 2016). Knee fractures may be painful and may also interfere with the proper functioning of

the knee, causing pain during movement and when carrying heavy objects (Jackson et al., 2016).

The patient's pain could be a result of knee bone fracture (Jackson et al., 2016). Investigating the

recent patient's activities would help to identify any risk of a fracture. An X-ray can also be used

to check if a fracture or other medical conditions causing the patient's pain.


Meniscus injuries. The knees have menisci made of cartilage and acts as a cushion between the

bones and the knee (Jackson et al., 2016). Twisting the knee can cause injuries to the meniscus

leading to knee pain (Jackson et al., 2016). The physician should investigate if the patient, in this

case, had twisted their knees recently.

Patellar tendinitis. This is an injury to the tendon that connects the kneecap to the shinbone

(Jackson et al., 2016). Symptoms of patellar tendinitis include pain, hindered mobility, swelling,

and redness (Jackson et al., 2016). The patient, in this case, could have injured their patellar

tendons, which could be contributing to the pain. Furter laboratory assessments are needed to

confirm the diagnosis.

PLAN:

Medication discontinued: Hydrochoroqune Sulfate 200MG 1 tab BID with food or milk,

Plaquenil 200 MG 1 tab BID with food or milk, Sufasazaline 500 MG 2 tabs BID, Prednisone 5

MG 1 tab in the AM.

Medication started: We are yet to decide the exact medicine for the patient. We are still

analyzing her drug allergies and alternative drugs.


Alternative therapies: Rheumatoid arthritis has no cure, and the only medication available can

be used to manage the symptoms and improve the quality of life of the affected individuals. For

the patient mentioned in this case, he has already tried medication, which is suppressing his

immune system. Therefore, alternative ways to manage his symptoms could be more useful at

this point. Some alternative therapies include the following:

Rest and relaxation. We will evaluate the patient’s sleeping schedule and advise him

accordingly. If the patient is not getting enough sleep, he will be required to adjust his sleep

schedule to ensure he gets enough rest and relaxation. Getting enough sleep s important for

people with rheumatoid arthritis, the patient should try to sleep at least eight or seven hours

every night (Taibi & Bourguignon, 2018). If the patient sleep is negatively affected because of

stress, discomfort, or environmental factors, we will refer the patient to an expert who can guide

him through relaxation exercises to reduce stress and tension.

Exercise. We will also work with the patient to create a low-impact exercise program. Strenuous

activities can be uncomfortable and may lead to more pain, thus the need for a low-impact


workout (Taibi & Bourguignon, 2018). Examples of exercises we will recommend for the patient

include walking, gentle stretching, and water aerobics.

Fish and oil supplements. Some studies suggest that fish and oil supplements can help to reduce

pain and stiffness in rheumatoid arthritis (Taibi & Bourguignon, 2018). We may, or we may not

include this alternative therapy during treatment. Before recommending it, I will consult with my

preceptor and also research the complications associated with taking the supplements.

Heat and cold treatment. We will also recommend heat and cold therapy for the patient since it

helps to improve the quality of life of the patient. A cold treatment helps to reduce inflammation

and joint swelling (Taibi & Bourguignon, 2018). A hot treatment helps to relax the muscles and

increase blood flow (Taibi & Bourguignon, 2018).

Health promotion strategies and education: We will first explain to the patient the importance

of adhering to medication and attending all appointments. The patient claims to have quit some

drugs because they were suppressing his immune system. We will investigate whether the

patient’s decision was guided by a medical practitioner or from his personal choice. If the patient

quit the medication without professional advice, we will educate him on the dangers of taking


such actions and assess alternative drug options that can be used. We will also inform the client

on the risks of smoking. If the patient is willing to quit smoking, we will refer him to a mental

health professional to help him through his addiction. We will also assess the patient’s diet and

recommend some foods such as vegetables, whole grains, and fish. These foods are usually

recommended in rheumatoid arthritis patients. We will also educate the client on the importance

of regular physical activity. However, we will advise the patient to avoid rigorous exercise since

it can worsen his symptoms.

Disease prevention strategies

Since the patient has already used rheumatoid arthritis drugs, which are causing adverse effects,

we will only give him pain management drugs such as Advil. The patient is also scheduled for

surgery later this month. For medication, I will work with the preceptor to determine viable

medicines for managing the patient's symptoms.

Diagnostic tests: We have ordered a knee X-ray for the patient whose results will be collected

by the end of the week.


Referrals: The patient has a smoking problem; hence, we will refer him, with his consent, to a

psychotherapist to help him through his addiction. We will also refer the patient to a nutritionist

and a physiotherapist to guide him through his diet and exercise, respectively.

Follow-up: Before the surgery, the patient should visit the hospital every week for close

monitoring. After the surgery, the patient will stay for approximately one week in the facility and

have weekly appointments afterward.

Reflection:

This week's activities allowed me to interact with a patient with a knee complication. The

experience was enlightening because I learn that knee pain can be caused by autoimmune

infections such as rheumatoid arthritis. I also came to understand that rheumatoid arthritis is

highly prevalent among people who have a family history of the condition. I also learned that

smoking also increases the risk of rheumatoid arthritis. I also learned that rheumatoid arthritis is

an autoimmune disease, and the drugs used for treatment aims at suppressing the body's immune

system. Long-term use of the drugs can thus impair the body’s immune system. As a future


medical practitioner, I look forward to the invention of drugs that can manage rheumatoid

arthritis without adverse effects.


References

Davies, G. J., & Malone, T. (2017). Knee examination. Physical therapy, 60(12), 1565-1574.

Felson, D. T. (2016). Osteoarthritis of the knee. New England Journal of Medicine, 354(8), 841-

848.

Firestein, G. S. (2017). Evolving concepts of rheumatoid arthritis. Nature, 423(6937), 356.

Jackson, J. L., O Malley, P. G., & Kroenke, K. (2016). Evaluation of acute knee pain in primary

care. Annals of internal medicine, 139(7), 575-588.

Taibi, D. M., & Bourguignon, C. (2018). The role of complementary and alternative therapies in

managing rheumatoid arthritis. Family & community health, 26(1), 41-52.

week 8 soap note knee assessment€¦ · week 8 soap note knee assessment 5 neck: neck is supple,...

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