SOAP #4 1
NURS 634SOAP NOTE MSK-Low Back Pain latest
SOAP # 4: MSK-Acute Low Back Pain
Shumeka Hill, APN, PNP-AC
UMASS
History & Physical Examination
,SOAP #4 2
Patient Demographics:
Name: T.H.
Age/race/sex: 26 Hispanic Female
Clinical site: Primary Care clinic; Presents for sick visit.
SUBJECTIVE DATA
Chief Complaints: “My lower back has been hurting for about 2 weeks now”.
History of Present Illness:
Mrs. H is a 26 y/o Hispanic female with a six year history of depression-
controlled on Sertraline, who presents to the clinic today complaining of
spontaneous occurring acute low back pain to lumber region that started
about 2 weeks ago after wearing heels to a party. Reports it has been very
difficult to dress lower body and to bend. She reports the pain is constant but
has intermittent intensities of aching and soreness throughout the day. The
pain is localized to the lumber area, described as aching and soreness with
no radiation, rated a 5/10 in office today with 3/10 being the lowest amount
of pain experienced and 8/10 being the worst pain she has experienced.
Reports the pain is worse in the mornings when getting out of bed after lying
down all night. She hasn’t tried any pharmacological or non-pharmacological
therapies. She reports no heavy lifting, strenuous exercise, current injuries,
nor feelings of anxiety or depression. However, about 5 years ago she was
riding her bike, went down a ramp and flipped head first over the handle
bars of the bike. At which time she experienced this same low back pain,
went to the ER and had X-rays that showed some inflammation and swelling.
She was then prescribed a muscle relaxant, Ibuprofen, and physical therapy
for 8 weeks, which helped tremendously. At today’s visit, she hopes to find
out where the pain is coming from and what she can do to prevent it from
returning.
Past Medical History:
• Depression-active- diagnosed 6 years ago after mom passed in a MVA
• Low back pain-active-diagnosed about 5 years ago after previous back injury.
Past Surgical History:
• No surgeries to date
Allergies:
NKA to food, dust, mold, environment, or medications.
, SOAP #4 3
Medications:
Sertraline 150 mg by mouth daily for depression
Health Maintenance:
• Influenza Vaccine-October 2017 at CVS.
• All other immunizations are up-to-date including TDaP, MMR, and Varicella.
• Last Pap smear- June 2016-normal
• Performs MSBE
• Depression screen positive for PHQ2; on meds and see Psychologists regularly.
• CAGE 0/4
Personal & Social History:
• Lives alone in a one bedroom apartment.
• Works at a nursing home as a Certified Nursing Assistant 4
days/week. She loves her job and has a dependable car.
• Denies any smoking, illicit drug abuse, or alcohol misuse.
• Previously did cross fit in high school. However, do to work she hasn’t
had much time to get the amount of exercise she needs.
• Patient is sexually active with only one sex partner, her boyfriend.
• 24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich,
chips, and a diet coke; S-about 1-2 cups of cheese-it crackers and a
diet coke; D- Meatloaf, veggies, mashed potatoes from Boston Market,
and a bottled water.
Family History:
Grandparents
Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76
history of DM and MI.
Maternal: Maternal grandfather died at 82 from MI, maternal grandmother
79, history of diabetes and arthritis.
Parents
Father: Father 59, history of HTN, Diabetes, Depression, and
Stroke. Mother: Mother 52, died in a MVA.
Siblings
Siblings: Only child.
Children
Children: No children.
Review of Systems:
NURS 634SOAP NOTE MSK-Low Back Pain latest
SOAP # 4: MSK-Acute Low Back Pain
Shumeka Hill, APN, PNP-AC
UMASS
History & Physical Examination
,SOAP #4 2
Patient Demographics:
Name: T.H.
Age/race/sex: 26 Hispanic Female
Clinical site: Primary Care clinic; Presents for sick visit.
SUBJECTIVE DATA
Chief Complaints: “My lower back has been hurting for about 2 weeks now”.
History of Present Illness:
Mrs. H is a 26 y/o Hispanic female with a six year history of depression-
controlled on Sertraline, who presents to the clinic today complaining of
spontaneous occurring acute low back pain to lumber region that started
about 2 weeks ago after wearing heels to a party. Reports it has been very
difficult to dress lower body and to bend. She reports the pain is constant but
has intermittent intensities of aching and soreness throughout the day. The
pain is localized to the lumber area, described as aching and soreness with
no radiation, rated a 5/10 in office today with 3/10 being the lowest amount
of pain experienced and 8/10 being the worst pain she has experienced.
Reports the pain is worse in the mornings when getting out of bed after lying
down all night. She hasn’t tried any pharmacological or non-pharmacological
therapies. She reports no heavy lifting, strenuous exercise, current injuries,
nor feelings of anxiety or depression. However, about 5 years ago she was
riding her bike, went down a ramp and flipped head first over the handle
bars of the bike. At which time she experienced this same low back pain,
went to the ER and had X-rays that showed some inflammation and swelling.
She was then prescribed a muscle relaxant, Ibuprofen, and physical therapy
for 8 weeks, which helped tremendously. At today’s visit, she hopes to find
out where the pain is coming from and what she can do to prevent it from
returning.
Past Medical History:
• Depression-active- diagnosed 6 years ago after mom passed in a MVA
• Low back pain-active-diagnosed about 5 years ago after previous back injury.
Past Surgical History:
• No surgeries to date
Allergies:
NKA to food, dust, mold, environment, or medications.
, SOAP #4 3
Medications:
Sertraline 150 mg by mouth daily for depression
Health Maintenance:
• Influenza Vaccine-October 2017 at CVS.
• All other immunizations are up-to-date including TDaP, MMR, and Varicella.
• Last Pap smear- June 2016-normal
• Performs MSBE
• Depression screen positive for PHQ2; on meds and see Psychologists regularly.
• CAGE 0/4
Personal & Social History:
• Lives alone in a one bedroom apartment.
• Works at a nursing home as a Certified Nursing Assistant 4
days/week. She loves her job and has a dependable car.
• Denies any smoking, illicit drug abuse, or alcohol misuse.
• Previously did cross fit in high school. However, do to work she hasn’t
had much time to get the amount of exercise she needs.
• Patient is sexually active with only one sex partner, her boyfriend.
• 24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich,
chips, and a diet coke; S-about 1-2 cups of cheese-it crackers and a
diet coke; D- Meatloaf, veggies, mashed potatoes from Boston Market,
and a bottled water.
Family History:
Grandparents
Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76
history of DM and MI.
Maternal: Maternal grandfather died at 82 from MI, maternal grandmother
79, history of diabetes and arthritis.
Parents
Father: Father 59, history of HTN, Diabetes, Depression, and
Stroke. Mother: Mother 52, died in a MVA.
Siblings
Siblings: Only child.
Children
Children: No children.
Review of Systems:
