Orthopedic SOAP Note Example

Patient Information

Name: J.D
DOB: 07/15/1974 (50 years old)
Date of Visit: 05/07/2025
Provider: Dr. Sarah Anderson, MD, Orthopedic Surgeon

SOAP Note

S – Subjective

Patient is a 50-year-old male presenting with chief complaint of “severe right knee pain that’s been getting worse for 3 months.” Patient describes pain as dull and aching, rating it 7/10 at worst, 4/10 at best. Pain worsens with weight-bearing activities, especially stair climbing and after sitting for prolonged periods (“morning stiffness lasts about 30 minutes”). Patient reports occasional “giving way” sensation when walking, denies locking. Tried over-the-counter NSAIDs with minimal relief. No history of acute injury, though patient mentions playing recreational basketball weekly for past 25 years. Denies fever, chills, or night pain.

PMH: Hypertension (controlled), Type 2 diabetes (A1c 6.7% last month)
PSH: Appendectomy (1992)
Medications: Lisinopril 10mg daily, Metformin 500mg BID, Naproxen 220mg PRN
Allergies: Penicillin (rash)
Family History: Father with osteoarthritis, mother with rheumatoid arthritis
Social History: Construction supervisor, requires frequent standing and occasional climbing. Non-smoker, social alcohol use (2-3 drinks/week), lives with wife in two-story home.

ROS:

• Constitutional: Denies fever, chills, fatigue
• Musculoskeletal: Endorsed as above, denies other joint pain or swelling
• Neurological: Denies numbness, tingling, weakness
• Skin: Denies rashes or skin changes
• All other systems were reviewed and negative

O – Objective

Vitals: BP 132/84, HR 72, RR 16, Temp 98.6°F, SpO2 98%, Weight 215 lbs, Height 5’11”, BMI 30.0

Physical Examination:

• General: Well-appearing male in no acute distress
• Gait: Antalgic gait favoring right lower extremity
• Right Knee:
  • Inspection: Mild joint effusion, no erythema
  • Palpation: Tenderness over medial joint line and medial femoral condyle
  • ROM: Extension 0°, Flexion 120° (limited by pain), compared to left knee Extension 0°, Flexion 135°
  • Special Tests:
    • McMurray’s test: Positive for medial compartment
    • Lachman test: Negative
    • Anterior/Posterior drawer tests: Negative
    • Valgus/Varus stress tests: Pain with valgus stress, no instability
  • Muscle strength: 5/5 quadriceps and hamstrings bilaterally
  • Neurovascular: Intact sensation, 2+ popliteal and dorsalis pedis pulses

Diagnostic Studies:

• X-ray Right Knee (3 views) obtained today:
  • Moderate medial compartment joint space narrowing
  • Marginal osteophytes on femoral condyles and tibial plateaus
  • Subchondral sclerosis in the medial compartment
  • No fracture or dislocation
• Previous labs (1 month ago):
  • ESR: 15 mm/hr (normal range 0-22)
  • CRP: 2.3 mg/L (normal range 0-3.0)
  • Uric acid: 5.2 mg/dL (normal range 3.5-7.2)

A – Assessment

1. Moderate osteoarthritis of right knee (ICD-10: M17.11), predominantly affecting medial compartment
2. Possible medial meniscus degeneration/tear based on positive McMurray’s test
3. Obesity (BMI 30.0) contributes to joint stress
4. Hypertension, controlled (ICD-10: I10)
5. Type 2 diabetes mellitus, controlled (ICD-10: E11.9)

Medical decision-making: Moderate complexity due to established diagnoses with worsening symptoms, moderate risk factors, and need for further diagnostic evaluation to determine optimal treatment approach.

P – Plan

1. Diagnostic:
   • MRI right knee to evaluate the status of menisci, cartilage, and ligaments
   • Weight-bearing AP view to better assess joint space narrowing
2. Therapeutic:
   • Prescription-strength NSAID: Meloxicam 15mg daily with food for 4 weeks
   • Activity modification: Avoid high-impact activities, basketball, and prolonged standing
   • Knee brace: Prescribed unloader knee brace for medial compartment OA
   • Physical therapy: Referral for 8 sessions focused on quadriceps strengthening, gait training, and pain management
   • Weight management: Goal to reduce BMI below 30, referred to a nutritionist
3. Education:
   • Discussed osteoarthritis pathophysiology, progression, and management options
   • Reviewed proper use of ice (20 minutes, 3-4 times daily)
   • Explained the importance of weight loss in reducing joint stress
   • Provided handout on low-impact exercises
4. Follow-up:
   • Return in 4 weeks to review MRI results and response to treatment
   • Discussed potential future interventions if conservative management fails:
     • Viscosupplementation injections
     • Corticosteroid injections
     • Possible surgical options include arthroscopy vs. osteotomy vs. arthroplasty, depending on disease progression and MRI findings
5. Contingency:
   • Contact the office if increased pain, swelling, redness, or new symptoms develop
   • Advised on proper NSAID use and potential side effects

This example demonstrates a comprehensive orthopedic SOAP note that includes all the essential elements while focusing on the specific needs of an orthopedic patient. The note captures the subjective information from the patient, documents objective findings from examination and diagnostics, provides a clear assessment of the condition, and outlines a detailed treatment plan.