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QUESTION
Title: Pt has a history of chronic lower back pain
Paper Details
soap note format
SOAP NOTE
Name: S.M.
Date: 10/03/17
Time: 0945am
Age: 30y
Sex: male
SUBJECTIVE
CC: Pt. states “I came in for lab work and adjustment of my medications (Bentyl), it’s not working, the pain is still there”
HPI:
Patient is a 30 years old AA male, with chronic back pain
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH
Allergies:
Medication Intolerances: NKA
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats, energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
Skin
Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
Eyes
Corrective lenses, blurring, visual changes of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
Breast
SBE, lumps, bumps or changes
Neurological
Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep – pending
Subject | Nursing | Pages | 12 | Style | APA |
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Answer
SOAP Note: Chronic Lower Back Pain
Name: S.M. |
Date: 10/03/17 |
Time: 0945am |
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Age: 30y |
Sex: male |
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SUBJECTIVE |
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CC: Pt. states “I came in for lab work and adjustment of my medications (Bentyl), it’s not working, the pain is still there” |
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Medications: Butalbital-Acetaminophen-Caffeine (Fioricet) 50-300-40 MG Oral Capsule for relief of back pain (Bryczkowski & Geib, 2012). Dicyclomine HCl (Bentyl) 10 MG Oral Capsule for treatment of stomach cramps (Medscape, 2017). Ibuprofen 600 MG Oral Tablet for pain relief (Drugs.com, 2017). Start: 08/07/17 Tramadol HCl (TraMADol HCl ER) 300 MG Oral Tablet Extended Release 24 Hour for relief of moderately severe pain (WebMD, 2017). Start:08/07/17
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PMH Allergies: No known allergies (NKA)
Medication Intolerances: NKA
Chronic Illnesses/Major traumas: Irritable bowel syndrome
Hospitalizations/Surgeries Pt was hospitalized five years ago (25 years) after sustaining back injury and major bruises following a motorbike accident. |
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Social History Pt is single and has a college degree and reports having met several friends in high school and college who influenced him to using drug and smoking. He works in one of the department stores where he occasionally participates in lifting of relatively heavy products. He smokes a pack of cigarettes in a day and reports occasional alcohol use. Besides, he admits of daily use of marijuana and frequent use of ecstasy.
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ROS |
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General No weight change over the last month. Energetic but may experience but may occasionally experience night sweats. |
Cardiovascular Cardiovascular parameters normal
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Skin Normal skin |
Respiratory Normal respiratory function
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Eyes Normal eye anatomy and physiology
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Gastrointestinal Abdominal pain and irritable bowel syndrome. |
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Nose/Mouth/Throat No sinus problems and no other issues of the mouth or the throat.
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Musculoskeletal Back pain and swelling |
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Breast Not applicable |
Neurological Tingling feet |
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Heme/Endo/Lymp HIV negative, increased thirst, and no history of blood transfusion. |
Psychiatric Normal mental status |
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OBJECTIVE |
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Weight: 70kg BMI: 23.66KG/m2 (Normal) |
Temp: 37°C (Normal) |
BP: 110/80mmHg (Normal) |
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Height: 172cm |
Pulse: 75 beats/min (Normal) |
Resp: 16 breaths/min (Normal) |
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General Appearance Healthy in appearance male with no sign of distress. He is oriented and alert and provides appropriate responses. |
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Skin Skin is warm, black, clean, intact and dry. No observable lesions or rashes. |
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Cardiovascular S1 and S2 with a consistent rhythm and pulse rate. There is absence of extra sounds, murmurs, rubs, clicks, or rubs. The capillary refill is two (2) seconds. Pulses are steadily 3+. No observable edema. |
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Respiratory The chest wall is symmetrical in shape. Respirations easy and regular. The lungs are both bilaterally clear to auscultation. |
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Gastrointestinal Abdomen is not obese. The bowel signs are active in all four quadrants. The abdomen is non-tender and soft. Hepatosplenomegaly is not observed. |
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Breast Not applicable |
(201
Genitourinary Non-distended bladder. The two testicles are palpable. No lesions or masses in either of the testicles. No urethral discharge and no hernia. The prostrate is non-tender, smooth, firm sphincter normal in size, and free from nodules. |
Musculoskeletal Chronic low back pain. |
Neurological Posture is erect. Clear speech. Good tone. Stable Balancing. Normal gait. |
Psychiatric Alert and oriented. Dressed in clean jeans and T-shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. |
Lab Tests Urinalysis results are pending Urine culture results are pending Wet prep results are pending
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Special Tests X-ray imaging shows degenerated or bulging lumbar vertebral disc. It is potential anatomical source of the pain. The reported back pain can have different pain generators, thus a multidisciplinary diagnosis is required (Allegri et al., 2016).
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Diagnosis |
Plan/Therapeutics |
o Plan: § Further testing Lab test will disclose if there is suspected kidney damage. Biochemical and serological test is required to test for possible liver damage. Magnetic resonance and imaging is required to test for possible spinal cord injury. § Medication No need for change of Bentyl. The current medication plan should continue. § Education Patient education should focus on adherence to medication and primarily the importance of Bentyl in for treatment of irritable bowel syndrome. § Non-medication treatments Limiting or possibly stopping alcohol, bang, and ecstasy use. Increased bed rest time and stopping the lifting of heavy equipment and goods as usual in the department store to allow the vertebral degeneration to recover. |
References
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