Subjective (S):

Objective (O):

• General: Alert, oriented x3, no acute distress.
• Head: Normocephalic, atraumatic.
• Eyes: PERRLA, EOMI, no scleral icterus or conjunctival injection.
• Neck: Supple, no lymphadenopathy or meningismus.
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
• Respiratory: Lungs clear to auscultation bilaterally, no rales, wheezes, or rhonchi.
• Abdomen: Soft, non-tender, no masses or organomegaly.
• Musculoskeletal:
• Neurological: Sensation intact to light touch in L4-S1 dermatomes, strength 5/5 in bilateral lower extremities, patellar and Achilles reflexes 2+ bilaterally.
• Special Tests:

Assessment (A):

Selected ICD-10 Codes:

Plan (P):

• NSAIDs as needed (e.g., ibuprofen 600 mg TID with food for 7 days)
• RICE protocol: rest, ice, compression, elevation
• Activity modification: avoid stairs, kneeling, deep flexion
• Begin quadriceps/gluteal stretching and strengthening exercises
• Physical therapy referral for evaluation and management
• Return in 7–10 days if not improved, sooner if worsening

Patient Handout:
You’re experiencing joint pain likely due to muscle strain or repetitive movement. Take ibuprofen as directed, use ice, and rest the knee. Avoid squatting or heavy use. If you notice popping, weakness, or it gets worse, call us.

🎉 Your note is ready to copy & paste!

Patient Instructions Only

You’re experiencing joint pain likely due to muscle strain or repetitive movement. Take ibuprofen as directed, use ice, and rest the knee. Avoid squatting or heavy use. If you notice popping, weakness, or it gets worse, call us.