SOAP Note Form

S/ Identifying Information: (initials, age/DOB, gender,

reliability)

Family Hx:

A.J. is 15 years old and a student. Parents are happily married and

financially stable. Dad having

hypertension and a high-stress

job. Also, her mom has weight

issues. Brother, as well as weight

problems and their grandfather,

ails from hypertension

Personal/Social Hx:

Chief Complaint/RFE: She denies alcohol, drugs, and the

use of any illegal substances. She

refuses any sexual encounters.

left leg pain after an injury

Hx Present Illness: (7 Variables but do not list as such)

The left leg knee injury. a.j had an injury 3 days ago on her left leg after landed in an

uncomfortable position in an uneven bars. Her legs pain is isolated in the front of her left knee,

injury very painful at night and becomes worse especially when awake. She is as well having

trouble while bending her knee

CURRENT HEALTH

Medications: Motrin 600 mg 3 to 4 times a day

Allergies: No allergies

Last PE & Screenings: Past six months

Immunization Status: HPV and Hepatitis A at the age of 11years

LMP & Birth Control (if applicable) LMP in the past month. No birth control

PMH

Illnesses & Trauma: No disease nor trauma

Hospitalizations/Surgeries: No illnesses nor surgeries

O.B. Hx/Sexual Hx: No sexual encounters, therefore, no sex

Emotional/Psy Hx: normal

REVIEW OF SYSTEMS

General: All review systems functioning normally

Nutrition: She consumes healthy diets.

Skin/Hair/Nails no compilations

HEENT: no complications

Breasts normal

Respiratory: No complications

CV/peripheral vascular no complications

GI Normal

GU Normal

MSK: Normal

Psych Normal

Neuro Normal

Lymph/Heme/Endocrine: Normal

O/ Physical Exam: T: 37.0 c P: R:16 B.P.: 110/72

HT: 5’ 6.” WT: 70.5 KG BMI: 25.1

General :Normal

Skin no complications

Head Normal

EENT :No complications

Neck no comlications

Breasts/Chest Normal

Lungs : Normal

Heart/ perip vascular Normal

Abdomen :No complications

Genitalia/Rectum no complications

Lymph Normal

MSK Normal

Neuro Normal

Medical Dx: (2max)

Stress fracture

Nerve entrapment

Rule Outs (only if applicable):

Health Profile:

age/gender/racial risks:

Pertinent Positives:(1DX)

No history of cigarette smoking, blood

pressure on exam, exertion chest pain,

personal/family:

screening needs:

and sexual encounters.

Pertinent Negatives:

No fevers, sputum, cough,

nausea, chest pressure, bloating,

vomiting, or hematemesis. No earlier

trauma history to the chest, more prior

coronary artery illness or anxiety.''

counseling needs:

Immunization/chemo needs:

Differential DX:(3-5) Alteration in Health Prevention R/T:

Quadriceps Tendonitis,

ITB syndrome and Patellar tendonitis.

Screening deficits:

Counseling deficits:

Nursing Dx: ITB syndrome. Immunization/chemo deficits:

I. PLAN: Do separate sections in the program to include: Max 1-2 pages

Diagnostics: ITB syndrome. Iliotibial Band Syndrome is an overuse injury of connective nerves

located on the outer part of the knee thigh. Pain and tenderness are caused by ITB and those

areas, especially above the joint of the knee. ITB is the leading cause of side knee pain in

cyclists and runners. The iliotibial band is a very thick fascia band that originates at iliac crest in

the pelvis and runs down the outside thigh part crossing the knee to fasten in the top part of the

shinbone. It is formed from tensor fascia lata and two of gluteal muscles in the buttock and

stretches crosswise the knee. It helps in stabilizing outside knee parts over its motion range. The

iliotibial band is a hip abductor muscle that moves the hip from the midline and also helps with

the flexion and extension of the knee. Inflammation may continue due to ignoring the

symptoms causing the development of scarring in the bursa and decreasing motion of the knee

range that caused an increased pain (Pegrum, Self, & Hall, 2019).

Medications/Treatments: ITB syndrome is treated with anti-inflammatory medications, like

naproxen (Aleve) and ibuprofen (Motrin and Advil). Home treatment can also be applied to the

patient, including stretching, use of foam rollers, and massage at the pain and inflammation site

(Pegrum, Self, & Hall, 2019).

Education: There is a need for educating the patients on the iliotibial band. The patient also

should be advised on the healthy diet because she is overweight.

Follow-up: Due to the ITB syndrome, A.J. will return to full activity of gymnastics as well as a

school when the pain has is fixed, including having achieved the usual flexibility of ITB. To

avoid the injury, recurrence should have recovered full strength of the muscle of proximal knee

and hip musculature.

Referrals: The patient will be referred to the lab for the knee tests and x rays to determine the

syndrome. She may as well be referred for doctors meeting in a week.

Prevention Plan: Most importantly, ITB syndrome patients should always reduce mileage

or take a few workdays off in case of pain on the outer side knee (Pegrum, Self, & Hall,

2019). She should also walk a half-mile before starting the exercises. In case the shoe soles

are worn out, they should be replaced before going for practices

II. Rationale: ( Max 2 pages)

Poor biomechanics particularly in rolling the knees and hips, weak hip, core muscles, hip

rotators, poor foot arch mechanism, and sudden increase in mileage for training. Any over the

encounter, medications to this syndrome may have possible side effects and also interactions

with prescribed medications.

Iliotibial band is an ensemble of fibrous tissues running down outside of the thigh. It is of

considerable significance since it provides stability to the knee and hip and helps in preventing

dislocation of the joints. The band might tighten, overdevelop and rub through the outer part of

the knee. When the knee is bend or hip flexed, the group rubs against the bone. This is common

to cyclists, runners, and people who participate in aerobic activities. It can be treated with the

rest, medicines to release pain and swelling and stretching movements as instructed by the

physical therapist.

III. Patho: (Max 2 pages)

The iliotibial band (ITB) is a thick fibrous tissue band originating from the anterior broader

iliac spike region extending down into the side portion of the thigh to the knee. It has inclusions

on the side tibia condyle and the distal portion of a femur. ITBS condition is a

knee pain resulting from the excessive friction of the ITB over the side femoral epicondyle. As

the knee bends from the full extension to nearly 30°, ITB moves backward and crosses the

femoral epicondyle.

Reference

Pegrum, J., Self, A., & Hall, N. (2019). Iliotibial band syndrome. bmj, 364 l980. ,