NURS 623 SOAP note topic based adult 2 week 12.

NURS 623 SOAP note topic based adult 2 week 12.O.A.P. Note Chief Complaint I’ve had pain in my lower back for a week and it's getting worse. History of Present Illness A 42-year-old obese female presents with complaints of lower back pain for the past week that feels worse today. The pain is constant and intermittently radiates down her left leg. It is not improved with ibuprofen. She reports that reclining in a recliner helps alleviate the pain and lying flat makes it worse. Past Medical History Past Medical history: None Past surgical history: None Patient is current in her immunizations No known allergies Current medications include: Ibuprofen 600 mg PO Q4 hours PRN Family History Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses Mother: Type 2 diabetes, hypertension, hypothyroidism Father: Asthma, Hypertension Sister: Hypothyroidism Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known Patient works as grocery store clerk. She is a married heterosexual. Pt denies any alcohol or illicit drug use. She does not smoke or use chewing tobacco. Pt does not exercise and is on a regular diet. Review of Systems (as applicable to CC) • General: Negative for fever. Negative for fatigue. Negative for chills, and night sweats