Nursing Soap Note


Prepared by: Maria R. Ybarra, Sky Bridge Networks


  • Chronic knee pain especially after physical activity

  • Recently tiring easily and having shortness of breath

  • Night sweats and unexplained weight loss


  • Heart rate: 85 bpm

  • Blood pressure: 130/85 mmHg

  • Body Temperature: 98.4 F

  • BMI: 25.8 (normal)

  • Respiratory Rate: 18 breaths per minute


Patient is displaying abnormal fatigue, which together with the presence of night sweats and unexplained weight loss, could be indicative of a number of conditions, such as thyroid issues or even chronic illnesses. Chronic knee pain might be increase due to possible increase in physical activities or an underlying ongoing degenerative condition. Further testing is necessary to determine the root cause of these symptoms.


  • Order blood tests including a complete blood count (CBC), hormone levels, and inflammation markers

  • Refer the patient to a radiologist to conduct an X-ray or MRI of the knee

  • Suggest incorporating periods of rest in between physical activities, to limit the extent of knee pain

  • Follow-up session scheduled in two weeks to review test results and adjust treatment options based on findings

Nursing note:

The patient's vitals will need to be closely observed in the following sessions. The team will revaluate the patient's interventions based on the test results. All investigations will be done using state-of-the-art networked diagnostic and imaging equipment of Sky Bridge Networks.

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