Back Pain SOAP Note
Develop a SOAP Note for a patient you encountered who had a complaint of back pain.
Discussion 4: Chronic Lower Back Pain
SUBJECTIVE
Chief Complaint: Lower back pain
History Patient Illness: A 67-year old male patient I visited in my clinical was complaining of chronic lower pain. The patient reports that the pain began when he was young, and he has been experiencing the pain daily. The pain is characterized as a dull pain that radiates to the legs and arms. The intermittent pain in the spine is 3/10 on the pain scale. The aggravating factors include standing for a long time, but the relieving factors are resting and taking medication for the pain. The patient’s medication is oxycodone 5/325mg twice per day for controlling the pain.
Review of Symptoms:
General: No weight changes, fatigue, and no sleeping problems
Skin: Denies any complaint
HEENT: Head: Denies headaches, pain, injury, dizziness Eyes: Normal vision, denies any vision changes and eye pain; Ears- Denies hearing loss; nose: No rhinitis, nasal congestion, nasal discharges. Throat: No soreness, dryness, and dysphagia
Neck: Denies swelling, stiffness, neck pain, and tenderness
Respiratory: Denies coughing, wheezing, and shortness of breath
Neurological: Denies numbness, sensations, dizziness and tingling
Cardiovascular: Denies a past history of cardiovascular diseases
Gastrointestinal – Denies diarrhea, distress, heartburn, vomiting, melena, constipation
Psychiatric: Anxiety, denies depression, suicidal and homicidal ideations
Genitourinary: Denies nocturia, dysuria, hematuria
Musculoskeletal: mid-back chronic intermittent pain and skeletal, muscular spasm, abnormalities of gait and mobility
Endocrine- No issues
Pertinent Medical and Surgical History:
Athsclerotic heart disease native coronary artery
Hypertensive heart disease heart failure
Acute combined systolic & diastolic heart failure
Chronic obstructive pulmonary disease
Chronic venous hypertension
Morbid obesity
Caudal syndrome
Hyperlipidemia
Allergies: NKDA
Immunization: Current and up-to-date
Pertinent Medications
Atorvastatin 80 mg, Lisinopril 20 mg, Potassium chloride, Riociguat 2.5 mg, Albuterol Sulfate HFA inhaler, Tiotropium bromide, Spiriva 20 mg, Furosemide 20mg, Glipizide 5 mg, Metformin HCI 850 mg, Warfarin 5 mg, Aspirin 81 mg, Baclofan 20 mg, Naproxyn 500 mg, Lexapro 10 mg, and Benzodiazepine 2 mg.
Family and Social History:
The patient smokes a half a pack or less daily. The patient is married. Both parents are deceased due to heart failure.
OBJECTIVE
Vital Signs
Vitals: T-97.9o F, RR-17, HR-68, BP-110/70, PO2-93% on room air, 2 out of 10 on the pain scale
Physical Examination
General Appearance: The patient is well-groomed, alert, and no physical distress
HEENT: Atraumatic, perfect dentition, pink & moist MM, EAC clear, PERRLA, no obstruction, clear throat, and scleral icterus
Neck: Negative carotid bruit, nodules, thyromegaly, JVD, and masses.
Skin: Warm, dry, no cyanosis, abscesses, lesions
Respiratory: No wheezing, and presence of lung sounds that are diminished in the lower lobes bilaterally
Cardiovascular: Regular S1S2, no murmurs, rubs, and gallops
Gastrointestinal: Soft, bowel sound normative in four quadrants, negative hepatosplenomegaly, moderate tenderness to palpations in the epigastric region
Musculoskeletal: Presence of equal strength and pedal pulses, negative for swelling in the tissue and joint pain
Neurological: Speech clear, normal gait, stable balance, alert and oriented 4
Psychiatric: Positive anxiety, denies depression, suicidal and homicidal ideation
ASSESSMENT
The patient complaints of chronic lower back pain and anxiety
Diagnosis:
Caudal syndrome; chronic obstructive pulmonary disease; anxiety, and Asthma
Differential Diagnosis:
Cauda equina-There is no perianal numbness and urinary retention, overflows, incontinence Extraspinous nerve entrapment- There is no abdominal mass and spinal mass
Demyelination condition- There is no clonus
Thoracic cord compression -There is no clonus, higher sensory pattern, and reflex in the abdomen
PLAN
Most patients with lower back pain improve in one to four weeks. A Conservative therapy plan is indicated after ruling out all differential diagnoses. The treatment will consist of NSAIDs, or else severe pain necessitates muscle relaxant or opioids, for one to two weeks. The patient should continue with current medications the same dosages that include oxycodone, baclofen, and naproxen. The patient should continue with Asthma, COPD, anxiety medications. The patient has previously prescribed nerve blocks, physical therapy, exercise, and epidural injections, but was not successful in controlling the back pain. Intensive rehabilitation for chronic back pain is cost-effective. It leads to the reduction of disability and fewer complications than surgery, though research has proven that it is somewhat less effective compared to spinal fusion surgery. Patient education consists of good body mechanics and recommendations for lifestyle modifications, smoking cessation, and weight loss. The patient can be referred to a specialist dependent on the MRI or radiographic results. He should be followed up in one week for evaluation.
References
Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017). Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.
Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.