Episodic Visit: Musculoskeletal Focused Note (Left knee pain)
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Soap note is on Muskuloseletal complaint. There are many physical exam tests out there that can be utilized when assessing the patient and these tests sometimes give you the diagnosis without having to utilize expensive and unnecessary imaging modalities. For example, someone who lifts a heavy box c/o lower back pain that radiates down their right leg. The straight leg test when elicited and pain is reproducible means that the patient has radiculopathy. Also, utilize dermatome information as it can help you distinguish which part of the spine is possibly affected.
Below is an excellent link to many physical exam tests. I want you to include one test in your soap note. 10 points will be taken off if not included. You do mention the name of the test, whether positive or neg, and what it shows if it were positive. So from my previous example, I would say NEG straight leg raise will help decrease the chances of the patient having radiculopathy.
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