Episodic/Focused SOAP Note for Knee Pain Patient Information: Case #3. Patient Initials: A.J. Age: 15 Gender: Male Subjective Chief Complaint (CC) : Knee Pain History of Present Illness (HPI): A.J. is a 15-year-old male who presented to the clinic with a complaint of dull pain in both knees which started 4 days ago. A.J. reports that one or both knees click sometimes, and he experiences a catching sensation under the patella. A.J. reported that the pain is constant, and prolonged standing and running makes it worse. A.J. reports he twisted his knees while playing basketball 4 days ago. He also stated that he has not been able to play with his basketball team because of the pain. A.J. reports that he has been wearing a knee brace whenever the pain became unbearable and sometimes took ibuprofen for the pain, whi8ich was temporarily effective. A.J. reports his pain at the time of assessment is 6/10. Medications: Daily Multivitamin. Allergies: Penicillin. Past Medical History (PMH): Seasonal allergies. Past Surgical History (PSH): None. Immunization History: Flu shot received this season. Significant Family History: Maternal grandmother suffers from osteoarthritis. Social History: Attends school regularly, plays basketball with his high school team. No illicit drug or alcohol use.
Review of systems: General: No fever, chills or fatigue reported. Neck: No pain, injury, or history of disc disease or compression. Musculoskeletal: No arthritis, gout. Limited range of motion in affected knees. No history of trauma or fractures. Allergic/Immunologic: Seasonal allergic rhinitis.
- Summer '15
- Spinal disc herniation, Anterior Cruciate Ligament