Response to

Sharda Vekariya 

Week 8, Initial Post


Top of Form

Episodic/Focused SOAP Note for Knee Pain

 Focused SOAP Note for KV with right knee pain

Patient Information:

Initials: KV,    Age: 19,          Sex: F,            Race: Asian


CC “My knee hurts”.

HPI: KV is a 19-year-old Asian female presented to this clinic today with a gradual onset of right knee pain, which began five days ago. She described the pain as “Sharp” and is rated 5 out of 10 on a severity pain scale of 0-10 x 5 days. Reported constant localized pain. The pain is located on the medial upper side of the knee without any associated symptoms. She reports feeling anxious and fearful. She reports falling last week during soccer practice and applying ice to her knee with some relief. The patient tried Advil 200 mg with minimal relief with pain but noted more swelling and pain today. Reports need to use crutches for ambulation, pain increases with placing weight on right leg.

Current Medications:
· Advil 200 mg Q6 hr prn pain, last dose 8 am on 07/20/21
· Tylenol 325 mg 2 tabs prn headache, last dose 1 month ago
· Zoloft 50 mg PO BID Anxiety last dose 07/20/21
· Arnica 200, 5 globules for irregular menstruation 07/18/21


Penicillin: rash

· Fall
· Headache
· Irregular menstruation


· Childhood immunization UpToDate
· HPV vaccine 2020
· Tdap vaccine 2020
· Covid-19 vaccine x2 dose 2021


· Denies surgical history

Soc Hx: Works part-time at a tutoring center and completing bachelor’s studies in science. Her hobbies include playing soccer, traveling, and listening to music. She has access to healthcare and medications through health insurance from work. She lives with a friend in a rental apartment in a moderately safe area. She denies using a cellphone and always uses a safety belt while driving. She reports having good social support from family and friends. She identified as a straight woman and had one previous healthy relationship with a boyfriend of 2 years. She reported her relationship ended due to different interests in life. She is an atheist by religion.  
· Denies substance use or drugs
· Denies use of tobacco or e-cigarette

Family Hx:
· Father: Diabetes, Hypertension, Hyperlipidemia, alive, age 51 yrs.
· Mother: Arthritis back, Depression, Gout, alive, age 54 yrs.
· Maternal grandfather: hypertension, died of heart attack @ age 42 yrs.
· Maternal grandmother: Arthritis, alive, age 76 yrs.
· Paternal grandfather: Hypertension, smoker, alive age 82 yrs.
· Paternal grandmother: Hypertension, diabetes, died of hypotension during dialysis, age 72 yrs.
· Brother: Obese, age 26 yrs.

Review of System:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Head: Reports occasional headaches. Denies visual loss, blurred vision, or double vision. Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching, extra growth, or dryness

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