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NJ

Nimali Jayasinghe

Patient ID: PAT004
Age: 50
Gender: Female
Blood Group: AB+
Phone: +94771234573

1

Clinical Notes

0

Prescriptions

2

Lab Orders

2

Radiology Orders

Recent Vital Signs

Recorded: 22 Sep 2025 01:12
Temp: 36.9°C
BP: 130/85
HR: 76 bpm
SpO2: 96%
Weight: 72.00 kg
BMI: 25.51

Clinical Notes

SOAP Note

by Dr. Dr. James Wilson • 22 Sep 2025 01:12

SOAP
DIAGNOSIS:

Osteoarthritis of right knee - acute exacerbation

SUBJECTIVE:

Patient reports increasing knee pain over past month, worse with activity and in mornings. Some stiffness.

OBJECTIVE:

Mild swelling of right knee. Crepitus on movement. Range of motion slightly limited. Gait normal.

ASSESSMENT:

Osteoarthritis flare-up. Conservative management appropriate at this stage.

PLAN:

NSAIDs for 2 weeks, physiotherapy referral. Consider intra-articular injection if no improvement.

Prescriptions

No prescriptions found

Medical History

Osteoarthritis

Onset: 30 Aug 2010 • Severity: Moderate

NSAIDs and physiotherapy

Chronic

Allergies & Alerts

No known allergies

Lab Orders

LAB003

Dr. Dr. James Wilson • 23 Sep 2025

Ordered
X-Ray Knee Joint
LAB004003

Dr. Dr. James Wilson • 22 Sep 2025

Processing
ESR
CRP
Rheumatoid Factor
Anti-CCP antibodies

Radiology Orders

RAD002

Dr. Dr. James Wilson • 23 Sep 2025

Scheduled
X-Ray - Knee
Knee pain evaluation
RAD004002

Dr. Dr. James Wilson • 22 Sep 2025

Scheduled
X-Ray - Knee (Right)
Knee pain and stiffness, assess joint space

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