Running head: SOAP NOTE 1

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Student's Name

Institutional Affiliation
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Soap Note

Subjective Data

The patient, a 45year old male, sustained a knee injury after a fall. The right knee was caught

between two bars of the stair walls. The pain is described as a sharp and stabbing pain. The

patient uses ES Tylenol, heat application, and resting as mitigating factors; however, sometimes

the pain gets so severe that all these do not help. The level of pain is 8/10, which is severe while

standing for long. The patient describes the pain as sharp and annoying and says, "sometimes the

pain is not inside the knee." The patient also complains of shortness of breath but denies chest

pains and musculoskeletal injuries. Conduct ultrasound imaging and MRI.

Objective Data

The patient had typical vital signs. The physicals signs observed around the bruised wound area

are slight inflammation bruising along the knee region, pain, and stiffness. Conduct quick

therapeutic exercise, conduct seated balance activities, knee extension, and hip flexion, and the

patient needs about 25% verbal cues to correct during these activities.

Primary and differential Diagnoses

The patient had a medical history of asthma and bipolar disorder. A left anterior crucial ligament

from a basketball injury. These conditions could have a significant contribution to the patient's

state. Bipolar disorders could affect cognitive functions (Vieta et al., 2018). The functions have

notable effects on psychomotor functioning. Bone marrow stromal cells are affected by asthma

medication (Nemeth et al., 2010). The patient does not either smoke or use recreational drugs,

and he exercises regularly; therefore, the most probable cause of a bone dislocation is asthma

drugs.
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Laboratory Tests

A lab test should be conducted on the bone marrow to determine the viability of erythrocytes and

leukocytes. Conduct a PFT and spirometry test, a simple breathing test to test the lungs' capacity

to hold. Conduct a sputum test and bronchial biopsy to measure the levels of eosinophils

(Stewart, 2018). Which is a particular type of white blood cells causing asthma

Plan and medication

After physiotherapy, the patient is provided with a workout worksheet to help exercise the

twisted knee (Beaufils et al., 2009). Breathing difficulty could be a relapse of asthma; therefore,

asthma treatments are recommended. Give antibiotics and painkillers to help with the pain: anti-

inflammatory drugs, oral steroids, or inhalers.

Non-pharmacological treatment and patient education

The patient should be enlightened on anxiety management strategies to manage bipolar

conditions. A workout worksheet provided should include little training on how it should be

used.
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References

Beaufils, P., Hulet, C., Dhenain, M., Nizard, R., Nourissat, G., & Pujol, N. (2009). Clinical

practice guidelines for managing meniscal lesions and isolated lesions of the anterior

cruciate ligament of the knee in adults. Orthopaedics & Traumatology: Surgery &

Research, 95(6), 437-442.

Nemeth, K., Keane-Myers, A., Brown, J. M., Metcalfe, D. D., Gorham, J. D., Bundoc, V. G., ...

& Mezey, E. (2010). Bone marrow stromal cells use TGF-β to suppress allergic responses

in a mouse model of ragweed-induced asthma. Proceedings of the National Academy of

Sciences, 107(12), 5652-5657.

Stewart, J. (2018). 3 asthma tests used to diagnose eosinophilic asthma | Everyday health.

Retrieved March 26, 2021, from

https://www.everydayhealth.com/hs/asthma/eosinophilic-asthma-tests/

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., ... & Grande, I.

(2018). Bipolar disorders. Nature reviews Disease primers, 4(1), 1-16.