SOAP Note: Integumentary and Musculoskeletal Systems

“I came to the clinic today because I have been having malaise, fatigue, and a rash on my chest for the past one week, and upon waking up today, I developed a swollen right knee which was quite painful.”

BJ was feeling well until last week, when he started developing a generalized malaise, and fatigue prevented him from doing his normal activities, such as walking back home from work. The malaise has been progressive, and today morning, when he woke up, he could hardly get out of bed and had a swollen, painful, and stiff right knee. He also saw a rash on his upper trunk. The patient states the pain in his knee was of sudden onset, dull, non-radiating, and he rated it at 7/10. It aggravated when standing and walking and relieved at rest. B.J. states that the rash, malaise, and fatigue began after he had visited a Lyme endemic area. He also presented with such symptoms as neck stiffness, low-grade temperature, and a headache. However, he denies any past knee pain, injuries, joint symptoms, chills, recent infection, nausea, or vomiting. He also denies any family history of joint disease.

None.

Allergies:

B.J. states that he has no known environmental, drug, or food allergies.

Medication Intolerances:

None.

Chronic Illnesses/Major Traumas:

Denies any past diagnosis of diabetes, hypertension, TB, peptic ulcer disease, or asthma.

Hospitalizations/Surgeries

He states that he was only hospitalized once when he fell and was unconscious after a football match ten years ago. He has never had any surgeries.

B.J’s father died of prostate cancer at the age of 65. His mother has peptic ulcer disease, and his two elder brothers are alive and well without any health concerns.

BJ’s is a law graduate currently pursuing his Master’s degree and working at his uncle’s law firm as an advocate. He lives in an apartment house with his girlfriend and their two-year-old son. He smokes about six cigarettes daily and drinks about five bottles of beer almost every weekend. He denies taking any drugs.

B.J. states that he has a slight fever and generalized fatigue. Denies any weight changes within this period. Denies any night sweats and alterations in his energy levels.

He has no pains in his chest, paroxysmal nocturnal dyspnea, peripheral edema, and heart palpitations.

B.J. states that he has an erythematous rash on his chest area that seems to be expanding and has a distinct shape. He denies any delayed wound healing, skin discolorations, lesions, moles, easy bruising and bleeding.

He has no cough, wheeze, dyspnea, or hemoptysis. He has no history of TB or pneumonia.

The patient uses corrective lenses because he is short-sighted. Denies blurred vision, eye discharge, or changes in his normal vision.

The patient denies any abdominal pain, nausea, vomiting, hepatitis, stool changes, eating disorders, ulcers, hemorrhoids, and constipation.

He denies any ear pains, discharge, ringing, or loss of hearing.

Denies urinary frequency, urgency, hematuria, burning, or changes in the color of urine. He is sexually active and uses condoms during each sexual intercourse. He has never had a PSA test done before.

The patient has no sinus issues, nose bleeding, or discharge. He denies dysphagia, throat pain, hoarse voice, and any dental diseases.

B.J. has a swollen knee that is very painful. He also has a stiff neck. He denies any back problems, osteoporosis, or fracture.

B.J. has never performed any self-breast exam. Denies breast lump, lesion, discharge and breast color changes.

He has weakness in the affected limb but denies seizures, paralysis, syncope, blackout spells, and pins and needles sensations.

HIV negative. He denies easy bruising and bleeding, blood transfusion, night sweats, lymph node enlargement, increased hunger or thirst, and cold or heat intolerance.

He denies any anxiety, suicidal thoughts or attempts, depressive episodes, difficulties in sleeping, and previous mental illness.

The patient is a healthy-looking Caucasian adult male with slight distress. He seems to be favoring his right leg while walking into the room. He is alert and oriented to time, person, and place. He is in a dull mood.

His skin is warm and supple with normal turgor and no rashes. Erythema is present circumferentially on the right knee and extends about 3 cm below and above the patella bone.

The head has no visible traumas; it is normocephalic without deformities. The hair is dark and evenly distributed on his head. PERRLA/EOMI is normal. No scleral icterus or conjunctival injection present. He has no facial asymmetry; the nasal mucosa is pink with normal turbinates and no septal deviation. The ear canals are patent with normal pearly gray tympanic membranes; bilateral and normal positive light reflex. The neck is supple with limited movement due to stiffness. He has no lymphadenopathy, thyromegaly, or nodules. The oral mucosa is moist and coral pink with a non-erythematous and non-exudative pharynx. The teeth are white and healthy.

S1 and S2 are heard. The rate and rhythm are regular. No S3, S4, murmurs, or peripheral edema. The capillary refill time and pulses are normal.

The chest wall is symmetrical, and on auscultation, the lungs are clear. The respirations are regular.

His abdomen is non-tender and non-distended. The bowel sounds three per minute and active in all quadrants. He has no organ enlargement.

His breasts has no discharge, discoloration of skin, or dimpling. They are not tender and have no masses.

His bladder is not distended, and he has no CVA tenderness. The external genitalia has normal hair distribution. Both testes are present and palpable with no lesions, masses, or hernia. He has no urethral discharge. The rectum is not bleeding; no fissures, hemorrhoids, or masses. The prostate is free from nodules, smooth and non-tender. Anal sphincter is firm and has a normal tone.

His right knee is swollen, warm and erythematous. The knee has limited flexion of 90 degrees but a full extension. There is an effusion in the suprapatellar region with no crepitus. The other limbs have a full range of motion, no erythema or effusion. The spine is normal.

B. J’s speech is clear. He has an erect posture with normal stability and gait.

The patient is alert and well-oriented. He is smartly dressed in a suit. His speech is clear; and he answers questions appropriately. He maintains eye contact throughout the session.

Complete blood count, ESR; arthrocentesis for joint fluid analysis, including culture and crystal analysis.

Lyme Elisa

1-Lyme Disease

2-Reactive arthritis

3-Septic arthritis

4-Crystalline arthropathy

Final Diagnosis

· Lyme disease.

The patient presented with symptoms of Lyme disease, including fatigue, malaise, fever, joint pain, and swelling (Walker, Colledge, Ralston, & Penman, 2014.). He also visited a Lyme endemic region, which predisposed him to acquire the condition.

· Further testing

Knee ultrasound

Knee X-ray

· Medication

Doxycycline 100 mg taken twice a day orally for 21 days to help manage the bacterial infection.

Ibuprofen 400 mg orally thrice a day to help with knee pain relief (Walker et al., 2014).

· Education

It is important to educate the patient regarding the health dangers of untreated Lyme disease.

Additionally, the patient should wear protective clothing when doing outdoor activities in the endemic areas.

He should also use an insect repellant during the activities to avoid bites.

· Non-medication treatments

The patient should have adequate rest until the treatment is completed.

He should use a heat pad around the knee and frequently use a warm compress to massage the area (Glynn & Drake, 2012).

The encounter was very interesting. The patient was very willing to participate in the session; I had a chance to also deal with a condition that I have never encountered in practice. However, I could not fully cover all the areas in the history as the examination took too long and the patient was very impatient. I will ensure that on my next encounter I cover all areas and spend less time.