NU605 Unit 5 Discussion

NU605 Unit 5 Discussion

Student Name

Purdue University Global

NU605 Transition to Practice

Prof. Name:

Date

NU605 Unit 5 Discussion

A focused SOAP note for a patient with acute right knee pain should clearly document the patient’s symptoms, examination findings, differential diagnoses, and treatment plan. In this case, a 25-year-old female presents with knee pain following a twisting injury while playing soccer, making a meniscal injury a leading consideration while also warranting evaluation for ligament damage and possible infection due to the presence of low-grade fever and joint inflammation.

Patient Overview

Sarah is a 25-year-old female who presents with acute right knee pain that began two weeks ago after sustaining a twisting injury during a soccer game. Her symptoms have persisted despite rest and are affecting daily activities such as climbing stairs and bending the knee.

Subjective Findings

Chief Complaint

The patient reports:

“Sharp, stabbing pain in the right knee that becomes worse when using stairs or bending the knee.”

History of Present Illness (HPI)

Sarah states that her pain started approximately two weeks ago immediately following a twisting injury while playing soccer. The pain is constant and is aggravated by physical activity. She notes partial relief with rest and the application of ice.

Key characteristics of the pain include:

• Sharp and stabbing in nature

• Located in the right knee

• Worsens with movement, especially bending and stair climbing

• Improves with rest and ice

• Associated with swelling and limited mobility

Past Medical History

The patient has no significant past medical history and denies any previous knee injuries or chronic medical conditions.

Review of Systems

Most systems were reviewed and found to be within normal limits (WNL). Pertinent findings include:

• Musculoskeletal: Right knee pain, tenderness, swelling, and decreased range of motion.

• General: Mild fatigue and a low-grade fever of 100.1°F.

Objective Findings

Vital Signs

• Temperature: 100.1°F

• Heart Rate: 80 beats per minute

• Blood Pressure: 128/76 mmHg

• Respiratory Rate: 12 breaths per minute

• Oxygen Saturation: 99% on room air

Physical Examination

General Appearance

The patient appears well overall but demonstrates mild discomfort secondary to knee pain.

Musculoskeletal Examination

Examination of the right knee reveals:

• Erythema (redness)

• Increased warmth over the joint

• Tenderness to palpation

• Joint effusion (swelling due to fluid accumulation)

• Limited flexion and extension

These findings are concerning for an internal knee injury and warrant additional diagnostic evaluation.

Neurological Examination

Neurological assessment of the lower extremities is normal. Sensation and reflexes are intact bilaterally.

Assessment

Based on the patient’s history and physical examination, several differential diagnoses should be considered.

Meniscus Tear

A meniscal tear is the most likely diagnosis due to the classic presentation of:

• Twisting mechanism of injury

• Persistent pain

• Joint swelling

• Reduced range of motion

Meniscal injuries are common among athletes and often require MRI confirmation.

Ligament Sprain

A ligament sprain, particularly involving the medial collateral ligament (MCL) or anterior cruciate ligament (ACL), may present similarly. However, ligament injuries are often associated with instability and may demonstrate less joint effusion in mild cases.

Patellar Tendinitis

Patellar tendinitis can cause anterior knee pain that worsens with activity. However, the patient’s history of trauma and joint effusion makes this diagnosis less likely.

Osteoarthritis

Although osteoarthritis may present with knee pain and stiffness, it is uncommon in younger adults and typically develops gradually rather than following an acute injury.

Septic Arthritis

Septic arthritis remains an important consideration due to the patient’s low-grade fever, warmth, erythema, and joint inflammation. Although less likely, prompt exclusion is essential because delayed treatment can result in permanent joint damage.

Plan

Patient Education

The patient was educated regarding the importance of conservative management using the RICE protocol:

• Rest

• Ice

• Compression

• Elevation

Additionally, she was advised to begin gentle home-based physical therapy exercises as tolerated and to avoid activities that exacerbate symptoms.

Diagnostic Work-Up

Further evaluation is recommended to establish a definitive diagnosis and rule out serious pathology.

Imaging Studies

• Plain radiographs (X-rays) of the right knee to evaluate for fractures or bony abnormalities.

• Magnetic Resonance Imaging (MRI) to assess for meniscal tears, ligament injuries, and soft tissue damage.

Laboratory Testing

The following laboratory tests are recommended to evaluate for possible septic arthritis:

• Erythrocyte Sedimentation Rate (ESR)

• C-Reactive Protein (CRP)

If clinical suspicion for infection increases, joint aspiration and synovial fluid analysis should also be considered.

Medication Management

The patient may take:

• Ibuprofen 600 mg orally every 6–8 hours as needed for pain relief, provided there are no contraindications to nonsteroidal anti-inflammatory drug (NSAID) use.

Consultation and Referral

Referral to an orthopedic specialist is recommended if imaging confirms structural damage or if symptoms fail to improve with conservative management.

Follow-Up Care

A follow-up appointment should be scheduled within one to two weeks to:

• Review imaging and laboratory results

• Reassess pain and mobility

• Modify the treatment plan if necessary

• Determine whether specialist intervention is required

Conclusion

This focused SOAP note highlights the importance of a structured approach to evaluating acute knee pain in young adults. Given the patient’s history of a twisting injury, joint effusion, and limited range of motion, a meniscal tear remains the leading diagnosis. However, clinicians should maintain a broad differential diagnosis and promptly exclude serious conditions such as septic arthritis through appropriate imaging and laboratory evaluation.

References

American Academy of Orthopaedic Surgeons. (2025). Meniscus tears. https://orthoinfo.aaos.org/en/diseases–conditions/meniscus-tears/

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer.

McCance, K. L., & Huether, S. E. (2023). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Elsevier.

NU605 Unit 5 Discussion

National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2024). Joint health and knee disorders. https://www.niams.nih.gov/health-topics/knee-problems

Porter, R. S., & Kaplan, J. L. (Eds.). (2025). The Merck Manual of diagnosis and therapy. Merck Sharp & Dohme. https://www.merckmanuals.com/professional