Musculoskeletal SOAP Note Example

Below is a nursing SOAP note for a musculoskeletal examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

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• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Cardiovascular SOAP Note Example
• Abdominal SOAP Note Example
• Neurological SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example
• Discharge SOAP Note Example

Subjective:

1. Chief Complaint: Patient reports left knee pain and difficulty walking.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started gradually three weeks ago.
   • Location: The patient reports experiencing the knee pain specifically on the medial aspect of their left knee.
   • Duration: The patient mentions that the pain has been persistent since its onset, with intermittent periods of exacerbation and improvement.
   • Character: The patient describes the knee pain as a sharp, stabbing sensation, which intensifies with weight-bearing activities and walking.
   • Aggravating Factors: The patient reports that the pain worsens with walking, going up or down stairs, and prolonged periods of standing.
   • Relieving Factors: The patient states that rest, elevation, and applying ice to the affected knee provide temporary relief.
   • Treatment/Interventions Tried: The patient has been taking over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief and using a knee brace for support.
3. Past Medical History: Document any relevant past medical conditions, surgical procedures, or previous musculoskeletal injuries that may be related to the current symptoms. Include details about any previous knee injuries or chronic knee conditions.
4. Allergy History: Inquire about any known allergies to medications, including NSAIDs or specific pain relievers. Note the type of reaction experienced and any known allergens to avoid.
5. Medication History: Record the patient’s current and past medication history, including prescribed medications, over-the-counter pain relievers, and any topical treatments used for joint pain.
6. Social History: Explore the patient’s occupation, hobbies, and any recent changes in physical activity levels or exercise routines. Assess any history of traumatic injuries or repetitive strain on the knee joint.
7. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the musculoskeletal system. Inquire about associated symptoms such as joint stiffness, swelling, instability, or difficulty performing daily activities.

Objective:

1. Vital Signs: Blood pressure: 120/80 mmHg, Heart rate: 76 bpm, Respiratory rate: 14 breaths per minute, Temperature: 36.8°C.
2. General Appearance: The patient appears in mild discomfort, favoring the left leg while walking. No signs of acute inflammation or joint deformities.
3. Musculoskeletal Examination: Inspection reveals no visible abnormalities or signs of swelling. Palpation elicits tenderness over the medial aspect of the left knee joint. Range of motion is slightly limited due to pain.

Assessment:

1. Medical Diagnosis: Medial meniscus tear in the left knee.
2. Problem Identification: Patient reports left knee pain and difficulty walking.
3. Relevant Findings and Abnormalities: Tenderness over the medial aspect of the left knee, limited range of motion due to pain.
4. Client Education Needs: Patient requires education on managing knee pain, activity modification, self-care measures, and the importance of follow-up appointments.

Plan:

1. Medical Interventions:
   • Recommend activity modification and rest to reduce stress on the knee joint.
   • Prescribe physical therapy for strengthening exercises and range of motion exercises.
   • Discuss the use of analgesics or NSAIDs for pain relief, as needed.
2. Patient Education:
   • Educate the patient on proper body mechanics and techniques for walking, climbing stairs, and getting up from a seated position.
   • Instruct the patient on the application of ice packs and the use of compression wraps to alleviate pain and swelling.
   • Discuss the importance of adhering to the prescribed physical therapy regimen and any postural modifications.
3. Referrals or Consultations:
   • Refer the patient to an orthopedic specialist for further evaluation and consideration of surgical intervention if necessary.
   • Schedule a consultation with a physical therapist to initiate a customized rehabilitation program.
4. Safety Measures:
   • Assess the patient’s home environment for any hazards or obstacles that may increase the risk of falls or worsen the knee pain.
   • Provide education on when to seek immediate medical attention for sudden worsening of symptoms or signs of infection.
5. Evaluation:
   • Schedule a follow-up appointment in two weeks to assess response to treatment, evaluate progress, and make any necessary adjustments to the management plan.
   • Monitor for any signs of worsening symptoms or complications related to the knee injury.

• This example demonstrates a musculoskeletal SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes vital signs and examination findings related to the musculoskeletal system.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification.
• The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.