Discussion: Assessing Muscoskeletal Pain
Focused SOAP Note for a patient with knee pain
CC “Knee Pain”
HPI: The patient is a 15-year old male who developed pain in both knees. The patient describes the pain as a “catching sensation” which occurs in the patella region. Getting information on the onset of the pain is imperative. Additionally, it is important to get information on the type of activity the patient indulges in for example, which sport the patient participates in or whether the pain was triggered by an event that occurred, for example, an accident.
Current Medications: The patient should indicate the whether he is on any medication to help rule out drug-induced diseases. It is also essential to inquire about whether they have been hospitalized in the past for a musculoskeletal condition and whether any medication was administered.
Allergies: It is important for the patient to mention whether they have any allergies to medication or food. The importance of noting allergies is to avoid hypersensitivity to some medication which may be fatal.
PMHx: The patient should mention the occurrence of any previous musculoskeletal condition and the time it occurred. Soc Hx: The patient should mention their occupation. Further, he should also mention whether they use any recreational substance such as alcohol or tobacco. It is important to investigate the physical activity of the patient in the last three months.
Fam Hx: For this specific case, the patient should mention any musculoskeletal con…
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