NURS 638: SOAP NOTE Lumbar Pain

NURS 638: SOAP NOTE Lumbar Pain SUBJECTIVE CC: "I have back pain" HPI: S.N. is a 75years old male, who came to the clinic today complaining of low back pain (5/10), which is exacerbated by physical activity and ambulation, and improves with rest. The pain appeared several days ago, after picking up an object from the ground; it is irradiated to right leg accompanied with numbness. He has been suffering HTN and obesity. He denies smoking, drinking alcohol, or using another illicit drug. Medications: Amlodipine 10 mg 1 tab po daily (antihypertensive) Diovan HTC 80/12.5 mg po daily PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas : Hypertension (401.1) controlled Hospitalizations/Surgeries : none Family History Mother death: Stroke, OA Father death: CDA, HTN, Obesity. Social History The patient graduated from college. Retired. He lives in a residential area with his wife. Denies substance use / abuse, ETOH, tobacco, marijuana. Immunization: Received flu vaccine in November 2015 Environmental hazard: Denies environmental hazard Diet: Drinks natural juices, coffee 1/2 cup every morning, and 8 glasses of water daily. Also eat healthily. Exercise and Leisure: Sedentary life, on weekends makes outdoor activities with his family. Sleep: Insomnia. ROS General Weakness. He seems ill Cardiovascular Edema in lower extremities. Skin Denies delayed healing, rashes, bruising, skin discolorations, or any changes in lesions or moles Respiratory Denies cough, wheezing, hemoptysis, dyspnea