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  1. 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

Answer

SOAP Note: Chronic Lower Back Pain

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”

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

 

 

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.

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. 

 

ROS

 

 

General

 No weight change over the last month. Energetic but may experience but may occasionally experience night sweats.

Cardiovascular

Cardiovascular parameters normal

 

 

 

Skin

Normal skin  

Respiratory

Normal respiratory function

 

Eyes

Normal eye anatomy and physiology

 

Gastrointestinal

Abdominal pain and irritable bowel syndrome.

 

 

Nose/Mouth/Throat

No sinus problems and no other issues of the mouth or the throat.

 

Musculoskeletal

Back pain and swelling

Breast

Not applicable

Neurological

Tingling feet

Heme/Endo/Lymp

HIV negative, increased thirst, and no history of blood transfusion.

Psychiatric

Normal mental status

OBJECTIVE

 

 

 

Weight: 70kg        BMI: 23.66KG/m2 (Normal)

Temp: 37°C (Normal)

BP: 110/80mmHg (Normal)

Height: 172cm

Pulse: 75 beats/min (Normal)

Resp: 16 breaths/min (Normal)

General Appearance

Healthy in appearance male with no sign of distress. He is oriented and alert and provides appropriate responses.

Skin

Skin is warm, black, clean, intact and dry. No observable lesions or rashes.

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.

Respiratory

The chest wall is symmetrical in shape. Respirations easy and regular. The lungs are both bilaterally clear to auscultation.

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. 

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

 

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).

 

 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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