Soap Notes # 2 Assignment (30%)
Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.
History of Present Illness: Mr. Peterson is 52-year-old male construction worker who presents to the clinic with symptoms of right knee pain related to a fall sustained at home one week ago while he was coming down the stairs. Patient states that he tripped and during the fall, the right knee twisted and was caught between two bars of the stair wells. Immediately after the fall, the pain was sharp and stabbing, and he was unable to walk straight and apply weight on the knee. He applied ice and took 800mg of Motrin and went to bed. Patient states he did not want to go to the emergency department due to the long wait. After 24 hours he applied warm compresses intermittently and took extra strength Tylenol as needed. Mitigating factors include ES Tylenol, heat application, and resting the knee. However, sometimes the pain is so severe that even Tylenol does not help. Aggravating factors are long standing, bending the knee, and climbing stairs. He describes the pain as sharp, and annoying at the same time. At present time he feels like "something is not right inside the knee”. Level of pain is 8/10. He denies previous musculoskeletal injuries. Patient also reports shortness of breath but denies chest pain.
PMH: Asthma, bipolar disorder. Left knee anterior crucial ligament (ACL) 10 years ago from basketball injury.
Past surgical history: Right hip replacement 15 years ago from kick boxing.
Medications/OTC: Theophylline, Prednisone, Singular, Geodon, Prozac, Benadryl, Tylenol as needed.
Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with diabetes type II.
Health Maintenance: Immunization up to date.
Social history: Patient does not smoke, drink or use recreational drugs. He maintains a regular diet and exercises 3 times a week. He has been married for 10 years and lives with his wife and one adult son, and one teenage daughter. He is a mathematics teacher in the same high school where he attends clinic. He sleeps well.
With the information provided above, please continue the patient’s soap note to include:
Subjective: A thorough review of systems
Objective: A thorough physical examination
Primary diagnosis: Must be supported by subjective and objective findings.
3 differential diagnoses with one citation for each ddx (APA formatted).
Diagnostic (if applicable)
Referral (if applicable)
Patient education and Health promotion (disease, lifestyle, medication safety and side
References: A minimum of 3 different peer-reviewed references are required for this assignment. All references must be properly APA formatted and published within 5 years.
Note: Please use the FNU soap note template. Review the soap note examples posted on Bb. Also, have the soap note rubric handy when completing your assignment.
Below is how an example of how a reference list looks like:
American Lung Association. (2009). Chronic obstructive pulmonary disease (COPD) fact sheet.
Retrieved on March 8, 2013, from http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html
American Lung Association. (2010). The promise of research. Retrieved on March 12, 2013,
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2012). Primary care: a
collaborative practice. St. Louis, Mo.: Elsevier/Mosby.
Durairaj, L. (2010). Disparities in lung disease: Ethnic & racial clues. Retrieved on March 7,
2013, from http://www.lung.org/assets/documents/publications/research-awardsnationwide/RAN0405_LR.pdf
Miravitlles, M. et al. (2010). Cost of chronic bronchitis and copd: 1-year follow-up study.
Retrieved on March 8, 2013, from https://journal.publications.chestnet.org/data/Journals/CHEST/21990/784.pdf
National Guideline Clearinghouse. (2010). Management of uncomplicated acute bronchitis in
adults. Retrieved on March7, 2013, from http://www.lung.org/finding-cures/research-news/promise-of-research/past-issues/por-spr
Niederman, M., S. et al. (2012). Treatment cost of acute exacerbations of chronic bronchitis.
Retrieved on March 11, 2013, http://www.ncbi.nlm.nih.gov/pubmed/10321424
Poole P, H. (2012). Prophylactic antibiotic therapy for chronic bronchitis and chronic
obstructive pulmonary disease (COPD) (Protocol), Retrieved on March 11, 2013, from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764/pdf
South Carolina Department of Health and Environmental Control. (2010). Identification and
elimination of health disparities among populations. Retrieved on March 8, 2013, from http://www.scdhec.gov/health/chcdp/tobacco/goal4.htm
Thomas, M. (2012). Acute bronchitis in adults. Retrieved on March 2, 2013, from
Why Work with Us
Top Quality and Well-Researched Papers
We always make sure that writers follow all your instructions precisely. You can choose your academic level: high school, college/university or professional, and we will assign a writer who has a respective degree.
Professional and Experienced Academic Writers
We have a team of professional writers with experience in academic and business writing. Many are native speakers and able to perform any task for which you need help.
Free Unlimited Revisions
If you think we missed something, send your order for a free revision. You have 10 days to submit the order for review after you have received the final document. You can do this yourself after logging into your personal account or by contacting our support.
Prompt Delivery and 100% Money-Back-Guarantee
All papers are always delivered on time. In case we need more time to master your paper, we may contact you regarding the deadline extension. In case you cannot provide us with more time, a 100% refund is guaranteed.
Original & Confidential
We use several writing tools checks to ensure that all documents you receive are free from plagiarism. Our editors carefully review all quotations in the text. We also promise maximum confidentiality in all of our services.
24/7 Customer Support
Our support agents are available 24 hours a day 7 days a week and committed to providing you with the best customer experience. Get in touch whenever you need any assistance.
Try it now!
How it works?
Follow these simple steps to get your paper done
Place your order
Fill in the order form and provide all details of your assignment.
Proceed with the payment
Choose the payment system that suits you most.
Receive the final file
Once your paper is ready, we will email it to you.
No need to work on your paper at night. Sleep tight, we will cover your back. We offer all kinds of writing services.
No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.
Admission Essays & Business Writing Help
An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.
Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.
If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.