Soap note musculoskeletal system

Make a SOAP Note Not a narrative essay: Assessing Muscoskeletal Pain
Note: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.

CASE: Knee Pain

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

knee

To prepare:

With regard to the case study you were assigned:

· Review this week's Learning Resources, and consider the insights they provide about the case study.

· Consider what history would be necessary to collect from the patient in the case study you were assigned.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):

1. A description of the health history you would need to collect from the patient in the case study to which you were assigned.

2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

3. List five different possible conditions for the patient's differential diagnosis, and justify why you selected each.

4. Include how the patient X-ray helped you to refine the differential diagnosis

REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.

Resources:

· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

o Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

o Chapter 21, “Musculoskeletal System” (pp. 501-543)

This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

o Chapter 22, “Limb Pain” (pp. 356-374)

This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.

o Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)

The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.

· Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

o Chapter 2, "The Comprehensive History and Physical Exam" ("Muscle Strength Grading"; p. 26)

o Chapter 4, "Pediatric Preventative Care Visits" ("Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam"; pp. 78–79)

Note: Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.

· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/