OLD FEMALE WITH KNEEPAIN["My knee
gave out during soccer game"] —2026
LOCATION :OUTPATIENT CLINIC WITH X-
RAY, ECG, AND LABORATORY
CAPABILITIES FULL CASE STUDY WITH A
SOAP NOTE
,COMPREHENSIVE CASE: LISA THOMPSON - ACUTE KNEE INJURY
PART 1: COMPLETE CASE NARRATIVE
URGENT CARE PRESENTATION
Time: 17:45, Urgent Care Center
Patient: Lisa Thompson, 28-year-old female, arrives via friend's car with
right knee splinted with ACE wrap and ice pack. Using crutches, non-
weight-bearing on right leg. Appears athletic, dressed in soccer gear.
Initial Impression: Young, healthy female with acute traumatic knee
injury during sports. Rule out ACL tear, meniscal injury, fracture.
Immediate Observations: Right knee visibly swollen, held in slight
flexion. Patient grimacing with any movement.
INITIAL EVALUATION
Vital Signs:
• BP: 118/76
• HR: 88 bpm
• RR: 16
• Temp: 36.8°C
• Pain: 7/10 at rest
Point-of-Care Assessment:
• Neurovascular Status: CRITICAL CHECK
o Dorsalis pedis pulse: 2+ bilaterally
, o Posterior tibial pulse: 2+ bilaterally
o Capillary refill: <2 seconds toes
o Sensation: Intact to light touch all dermatomes
o Motor: Able to wiggle toes, ankle dorsiflexion/plantarflexion
intact
• Observation: Moderate effusion, no visible deformity, no
ecchymosis yet
Immediate Actions:
1. ICE Protocol: Continue ice, elevation
2. Analgesia: Ibuprofen 600mg given
3. Imaging Ordered: X-ray right knee (AP, lateral, sunrise/merchant
views)
4. Crutch Training: Proper use confirmed
SYSTEMATIC ASSESSMENT
1. DETAILED HISTORY
Source: Patient is excellent historian, athletic, knows her body well.
History of Present Illness (HPI) - Mechanism of Injury Critical:
O - Onset: 2 hours ago during recreational soccer league game.
L - Location: Right knee, specifically "deep inside" and lateral joint line.
D - Duration: Immediate symptoms after injury, persistent.
C - Characteristics:
• Mechanism of Injury (CRITICAL DETAIL):
o "Non-contact injury" - no collision with another player