Make a SOAP Note Not a narrative essay: Assessing Muscoskeletal Pain Note:  Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance. CASE: Knee Pain A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform? To prepare: With regard to the case study you were assigned: · Review this week's Learning Resources, and consider the insights they provide about the case study. · Consider what history would be necessary to collect from the patient in the case study you were assigned. · Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis? · Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment): 1. A description of the health history you would need to collect from the patient in the case study to which you were assigned. 2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. 3. List five different possible conditions for the patient's differential diagnosis, and justify why you selected each. 4. Include how the patient X-ray helped you to refine the differential diagnosis REMINDER: Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD  makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too. Resources: · Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. o Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63) o Chapter 21, “Musculoskeletal System” (pp. 501-543) This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system. .

1. Make a SOAP Note Not a narrative essay:
Assessing Muscoskeletal Pain
Note:
Your Discussion post should be in the SOAP Note format,
rather than the traditional narrative style Discussion posting
format. Refer to the Comprehensive SOAP Template in the
attachments below for guidance.
CASE: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes
one or both knees click, and the patient describes a catching
sensation under the patella. In determining the causes of the
knee pain, what additional history do you need? What categories
can you use to differentiate knee pain? What are your specific
differential diagnoses for knee pain? What physical examination
will you perform? What anatomic structures are you assessing
as part of the physical examination? What special maneuvers
will you perform?
To prepare:
With regard to the case study you were assigned:
·
Review this week's Learning Resources, and consider the
insights they provide about the case study.
·
Consider what history would be necessary to collect from the
patient in the case study you were assigned.
·
Consider what physical exams and diagnostic tests would be
appropriate to gather more information about the patient's
condition. How would the results be used to make a diagnosis?
·

2. Identify
at least five
possible conditions that may be considered in a differential
diagnosis for the patient.
Address all these in the SOAP Note not an Narrative Essay
(Follow the SOAP Note Template on the attachment):
1.
A description of the health history you would need to collect
from the patient in the case study to which you were assigned.
2.
Explain what physical exams and diagnostic tests would be
appropriate and how the results would be used to make a
diagnosis.
3.
List
five
different possible conditions for the patient's differential
diagnosis, and justify why you selected each.
4.
Include how the patient X-ray helped you to refine the
differential diagnosis
REMINDER:
Please make a SOAP NOTE for this case. Make your own
patient’s data, applicable health history, review of systems,
P.E., labs, differential diagnosis, final diagnosis etc.
Incorporate the data from the case in the SOAP note that you
will do… This is not a narrative essay ok…. I need SOAP note

3. (Nurse Practitioner/RN/MD makes SOAP note)… Be guided
with the SOAP Note in the templates/exemplar… Don’t copy
paste. Formulate your own… Don’t forget to cite the Five
different possible conditions (Differential diagnosis) and have
Reference lists too.
Resources:
·
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015).
Seidel's guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby.
o
Review of Chapter 4, “Vital Signs and Pain Assessment” (pp.
50-63)
o
Chapter 21, “Musculoskeletal System” (pp. 501-543)
This chapter describes the process of assessing the
musculoskeletal system. In addition, the authors explore the
anatomy and physiology of the musculoskeletal system.
·
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016).
Advanced health assessment and clinical diagnosis in primary
care
(5th ed.). St. Louis, MO: Elsevier Mosby.
o
Chapter 22, “Limb Pain” (pp. 356-374)

4. This chapter outlines how to take a focused history and perform
a physical exam to determine the cause of limb pain. It includes
a discussion of the most common tests used to assess
musculoskeletal disorders.
o
Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)
The focus of this chapter is the identification of the causes of
lower back pain. It includes suggested physical exams and
potential diagnoses.
·
Sullivan, D. D. (2012).
Guide to clinical documentation
(2nd ed.). Philadelphia, PA: F. A. Davis.
o
Chapter 2, "The Comprehensive History and Physical Exam"
("Muscle Strength Grading"; p. 26)
o
Chapter 4, "Pediatric Preventative Care Visits"
("Documentation of Important Components of Age Specific
Physical Exams and Sports Pediatric Sports Participation
Physical Exam"; pp. 78–79)
Note:
Download this Adult Examination Checklist and Physical Exam
Summary: Abdomen to use during your practice musculoskeletal
examination.
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).

5. Adult examination checklist: Guide for musculoskeletal
assessment
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Musculoskeletal
Assessment was published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011).
Physical exam summary: Musculoskeletal system
. In
Mosby's guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
This Musculoskeletal System Physical Exam Summary was
published as a companion to
Seidel's guide to physical examination
(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright
Elsevier (2015). From https://evolve.elsevier.com/
·
Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P.,
Holt, H. L., & …Losina, E. (2011). Medical decision-making
among Hispanics and non-Hispanic Whites with chronic back
and knee pain: A qualitative study.
BMC Musculoskeletal Disorders
,
12
(1), 78–85.

6. Retrieved from the Walden Library databases.
This study examines the medical decision making among
Hispanics and non-Hispanic whites. The authors also analyze
the preferred information sources used for making decisions in
these populations.
·
Vismara, L., Menegoni, F., Zaina, F., Galli, M., Negrini, S., &
Capodaglio, P. (2010). Effect of obesity and low back pain on
spinal mobility: A cross sectional study in women.
Journal of Neuroengineering & Rehabilitation
,
7
(1), 71–83.
Retrieved from the Walden Library databases.
In this study, the authors explore the effect of obesity and
chronic low back pain on spinal mobility. The authors use range
of motion as a metric of spinal mobility.
·
University of Virginia. (n.d.).
Introduction to radiology: An online interactive tutorial
. Retrieved from
http://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging.
For this week, focus on skeletal trauma in musculoskeletal
radiology.
Media
Online media for
Seidel's Guide to Physical Examination
In addition to this week's resources, it is highly recommended

7. that you access and view the resources included with the course
text,
Seidel's Guide to Physical Examination
. Focus on the videos and animations in Chapter 21 that relate to
the assessment of the musculoskeletal system. Refer to the
Week 4 Learning Resources area for access instructions on
https://evolve.elsevier.com/
.
Optional Resources
·
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009).
DeGowin’s diagnostic examination
(9th ed.). New York, NY: McGraw Hill Medical.
o
Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)
In this chapter, the authors explain the physiology of the spine,
pelvis, and extremities. The chapter also describes how to
examine the spine, pelvis, and extremities.