Hi doctor! I have a knee pain.

Your SOAP note:
‍
Subjective:
‍The patient, presented with a chief complaint of knee pain. he patient described the pain as a dull ache with occasional sharp discomfort, especially when walking or climbing stairs.

Objective:Upon examination, the right knee appeared normal in terms of swelling, redness, or visible deformities. There were no signs of acute trauma or injury. Range of motion in the knee joint was slightly limited due to pain, with mild discomfort during flexion and extension. No joint instability was noted.

Assessment:
Knee Pain: The patient's presentation is consistent with non-traumatic knee pain. Possible causes may include overuse, strain, or early signs of osteoarthritis. Further evaluation is needed to determine the underlying cause.

‍Plan:
1. Ordered X-rays: To rule out any underlying structural issues such as osteoarthritis or joint degeneration.
2. Prescribed non-steroidal anti-inflammatory medication (NSAID) to manage pain and inflammation.
Advised rest, ice, and elevation (RICE protocol) to alleviate discomfort.
3. Recommended physical therapy to improve knee strength and flexibility.
4. Discussed activity modification to reduce strain on the knee, including avoiding high-impact activities.
5. Scheduled a follow-up appointment in two weeks to assess progress and discuss X-ray results.