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Back Pain SOAP Note

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.

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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.

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