Injury Assessment SOAP Notes Scenarios

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Sports Med 2
Fill out a SOAP note based on these scenarios
1.
Basketball Joe was the senior center on the men’s
basketball team. Before every game it is team tradition to
show each other up and see who has the best dunk. While
he is coming down from his dunk his teammate gets in
the way causing basketball Joe to land on a straight leg
hurting his left knee. He tries to walk it off but each time
he tries to straighten his leg shooting pain causes him to
flinch and retract his leg to a comfortable position. He
can put most of his weight on his injured leg. He is point
tender on the posteriolateral aspect of his left knee.
There is no deformity or discoloration at this point. His
AROM is non-existent with extension and hurts w/
RROM in flexion. Upon further inquiry you find out he
has had a previous h/o knee problems but it was his right
knee.
2. Jeremy was a junior football player for the BSU Broncos.
During the homecoming game against the rival team
Jeremy gets hit hard and goes down. He comes over to the
ATC complaining of pain in his left shoulder. While doing
a quick on site evaluation you find that his AROM is
painful in all directions and he can’t go past 90 degrees in
flexion, abduction, and horizontal adduction. Upon
RROM in these directions there is extreme pain and
decreased strength. Upon palpation you find point
tenderness over his AC joint (tip of shoulder) positive
piano key and squeeze test. He says that he did not put his
arm out to catch his fall. Instead he tucked his arm in and
landed on his shoulder. You take his shoulder pads off and
confirm visual deformity and discoloration around the AC
joint.
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