soap note form family hx -...
TRANSCRIPT
SOAP Note Form
S/ Identifying Information: (initials, age/DOB, gender,
reliability)
Family Hx:
A.J. is 15 years old and a student. Parents are happily married and
financially stable. Dad having
hypertension and a high-stress
job. Also, her mom has weight
issues. Brother, as well as weight
problems and their grandfather,
ails from hypertension
Personal/Social Hx:
Chief Complaint/RFE: She denies alcohol, drugs, and the
use of any illegal substances. She
refuses any sexual encounters.
left leg pain after an injury
Hx Present Illness: (7 Variables but do not list as such)
The left leg knee injury. a.j had an injury 3 days ago on her left leg after landed in an
uncomfortable position in an uneven bars. Her legs pain is isolated in the front of her left knee,
injury very painful at night and becomes worse especially when awake. She is as well having
trouble while bending her knee
CURRENT HEALTH
Medications: Motrin 600 mg 3 to 4 times a day
Allergies: No allergies
Last PE & Screenings: Past six months
Immunization Status: HPV and Hepatitis A at the age of 11years
LMP & Birth Control (if applicable) LMP in the past month. No birth control
PMH
Illnesses & Trauma: No disease nor trauma
Hospitalizations/Surgeries: No illnesses nor surgeries
O.B. Hx/Sexual Hx: No sexual encounters, therefore, no sex
Emotional/Psy Hx: normal
REVIEW OF SYSTEMS
General: All review systems functioning normally
Nutrition: She consumes healthy diets.
Skin/Hair/Nails no compilations
HEENT: no complications
Breasts normal
Respiratory: No complications
CV/peripheral vascular no complications
GI Normal
GU Normal
MSK: Normal
Psych Normal
Neuro Normal
Lymph/Heme/Endocrine: Normal
O/ Physical Exam: T: 37.0 c P: R:16 B.P.: 110/72
HT: 5’ 6.” WT: 70.5 KG BMI: 25.1
General :Normal
Skin no complications
Head Normal
EENT :No complications
Neck no comlications
Breasts/Chest Normal
Lungs : Normal
Heart/ perip vascular Normal
Abdomen :No complications
Genitalia/Rectum no complications
Lymph Normal
MSK Normal
Neuro Normal
Medical Dx: (2max)
Stress fracture
Nerve entrapment
Rule Outs (only if applicable):
Health Profile:
age/gender/racial risks:
Pertinent Positives:(1DX)
No history of cigarette smoking, blood
pressure on exam, exertion chest pain,
personal/family:
screening needs:
and sexual encounters.
Pertinent Negatives:
No fevers, sputum, cough,
nausea, chest pressure, bloating,
vomiting, or hematemesis. No earlier
trauma history to the chest, more prior
coronary artery illness or anxiety.''
counseling needs:
Immunization/chemo needs:
Differential DX:(3-5) Alteration in Health Prevention R/T:
Quadriceps Tendonitis,
ITB syndrome and Patellar tendonitis.
Screening deficits:
Counseling deficits:
Nursing Dx: ITB syndrome. Immunization/chemo deficits:
I. PLAN: Do separate sections in the program to include: Max 1-2 pages
Diagnostics: ITB syndrome. Iliotibial Band Syndrome is an overuse injury of connective nerves
located on the outer part of the knee thigh. Pain and tenderness are caused by ITB and those
areas, especially above the joint of the knee. ITB is the leading cause of side knee pain in
cyclists and runners. The iliotibial band is a very thick fascia band that originates at iliac crest in
the pelvis and runs down the outside thigh part crossing the knee to fasten in the top part of the
shinbone. It is formed from tensor fascia lata and two of gluteal muscles in the buttock and
stretches crosswise the knee. It helps in stabilizing outside knee parts over its motion range. The
iliotibial band is a hip abductor muscle that moves the hip from the midline and also helps with
the flexion and extension of the knee. Inflammation may continue due to ignoring the
symptoms causing the development of scarring in the bursa and decreasing motion of the knee
range that caused an increased pain (Pegrum, Self, & Hall, 2019).
Medications/Treatments: ITB syndrome is treated with anti-inflammatory medications, like
naproxen (Aleve) and ibuprofen (Motrin and Advil). Home treatment can also be applied to the
patient, including stretching, use of foam rollers, and massage at the pain and inflammation site
(Pegrum, Self, & Hall, 2019).
Education: There is a need for educating the patients on the iliotibial band. The patient also
should be advised on the healthy diet because she is overweight.
Follow-up: Due to the ITB syndrome, A.J. will return to full activity of gymnastics as well as a
school when the pain has is fixed, including having achieved the usual flexibility of ITB. To
avoid the injury, recurrence should have recovered full strength of the muscle of proximal knee
and hip musculature.
Referrals: The patient will be referred to the lab for the knee tests and x rays to determine the
syndrome. She may as well be referred for doctors meeting in a week.
Prevention Plan: Most importantly, ITB syndrome patients should always reduce mileage
or take a few workdays off in case of pain on the outer side knee (Pegrum, Self, & Hall,
2019). She should also walk a half-mile before starting the exercises. In case the shoe soles
are worn out, they should be replaced before going for practices
II. Rationale: ( Max 2 pages)
Poor biomechanics particularly in rolling the knees and hips, weak hip, core muscles, hip
rotators, poor foot arch mechanism, and sudden increase in mileage for training. Any over the
encounter, medications to this syndrome may have possible side effects and also interactions
with prescribed medications.
Iliotibial band is an ensemble of fibrous tissues running down outside of the thigh. It is of
considerable significance since it provides stability to the knee and hip and helps in preventing
dislocation of the joints. The band might tighten, overdevelop and rub through the outer part of
the knee. When the knee is bend or hip flexed, the group rubs against the bone. This is common
to cyclists, runners, and people who participate in aerobic activities. It can be treated with the
rest, medicines to release pain and swelling and stretching movements as instructed by the
physical therapist.
III. Patho: (Max 2 pages)
The iliotibial band (ITB) is a thick fibrous tissue band originating from the anterior broader
iliac spike region extending down into the side portion of the thigh to the knee. It has inclusions
on the side tibia condyle and the distal portion of a femur. ITBS condition is a
knee pain resulting from the excessive friction of the ITB over the side femoral epicondyle. As
the knee bends from the full extension to nearly 30°, ITB moves backward and crosses the
femoral epicondyle.
Reference
Pegrum, J., Self, A., & Hall, N. (2019). Iliotibial band syndrome. bmj, 364 l980. ,