NBMC Soap Note

Specialty: General Practitioner **Subjective:** * **Right Knee Pain:** Mrs. Eleanor Vance, a 68-year-old female, presents today complaining of worsening pain in her right knee over the past three months. She describes the pain as a dull ache, occasionally sharp, rating it 6/10 at its worst. It's exacerbated by climbing stairs and prolonged standing, offering some relief with rest and over-the-counter paracetamol. She denies any specific injury but notes a gradual onset. She reports stiffness in the morning lasting approximately 20 minutes. * **Fatigue:** Mrs. Vance also mentions feeling more tired than usual for the past month, attributing it to disturbed sleep due to the knee pain. She denies any new stressors, changes in diet, or other systemic symptoms like fever or weight loss. **Objective:** * **Vital Signs:** BP 130/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Height 160 cm, Weight 75 kg. * **Right Knee Examination:** Mild effusion noted, no erythema or warmth. Tenderness to palpation along the medial joint line. Range of motion is limited by pain, flexion to 100 degrees, extension to 5 degrees. Crepitus present with movement. Ligamentous stability appears intact. Mild quadriceps atrophy observed. * **General Appearance:** Well-nourished, appears comfortable at rest. No pallor or jaundice. **Assessment:** * **Osteoarthritis, Right Knee (Exacerbation):** The patient's history of chronic knee pain, exacerbation with activity, morning stiffness, and objective findings of effusion, tenderness, crepitus, and limited range of motion are highly consistent with an exacerbation of underlying osteoarthritis. The absence of specific injury points towards a degenerative process. * **Fatigue secondary to Chronic Pain:** Her reported fatigue is likely related to the chronic nature of her knee pain, disrupting sleep patterns and overall well-being. No other clear underlying cause for fatigue is apparent at this time. **Plan:** * **Osteoarthritis, Right Knee:** * Continue with paracetamol as needed for pain. Consider adding topical NSAID gel. * Referral to physiotherapy for strengthening exercises, pain management strategies, and mobility improvement. * Discuss weight management strategies, as a 5% weight loss can significantly reduce knee joint stress. * Schedule follow-up in 4 weeks to review symptoms and physiotherapy progress. Consider X-ray of the right knee if symptoms do not improve significantly. * **Fatigue:** * Encourage good sleep hygiene practices, particularly focusing on pain management at night. * Reassure that fatigue is likely linked to pain; it should improve as knee pain is managed. * Monitor for other symptoms if fatigue persists beyond pain improvement.