2023 Latest Revised
m m
Tina Williams “Acute Low Back Pain”iHuman
m m m m m
Tina Williams " Acute Low Back Pain" iHuman
m m m m m m m
History & Physical Examination
m m m
SOAPm#4 2
PatientmDemographics:
Name:mT.H.
Age/race/sex:m26mHispanicmFemale
Clinicalmsite:mPrimarymCaremclinic;mPresentsmformsickmvisit.
SUBJECTIVE DATA m
ChiefmComplaintsm:m“Mymlowermbackmhasmbeenmhurtingmformaboutm2mweeksmnow”.
HistorymofmPresentmIllnessm:
Mrs.mHmismam26my/omHispanicmfemalemwithmamsixmyearmhistorymofmdepression-
controlledmonmSertraline,mwhompresentsmtomthemclinicmtodaymcomplainingmofmspontaneousmoccurrin
gmacutemlowmbackmpainmtomlumbermregionmthatmstartedmaboutm2mweeksmagomaftermwearingmheelsmtom
amparty.mReportsmitmhasmbeenmverymdifficultmtomdressmlowermbodymandmtombend.mShemreportsmthempai
nmismconstantmbutmhasmintermittentmintensitiesmofmachingmandmsorenessmthroughoutmthemday.mThemp
ainmismlocalizedmtomthemlumbermarea,mdescribedmasmachingmandmsorenessmwithmnomradiation,mratedma
m5/10minmofficemtodaymwithm3/10mbeingmthemlowestmamountmofmpainmexperiencedmandm8/10mbeingmth
emworstmpainmshemhasmexperienced.mReportsmthempainmismworseminmthemmorningsmwhenmgettingmoutm
ofmbedmaftermlyingmdownmallmnight.mShemhasn’tmtriedmanympharmacologicalmormnon-
pharmacologicalmtherapies.mShemreportsmnomheavymlifting,mstrenuousmexercise,mcurrentminjuries,mno
rmfeelingsmofmanxietymor
depression.mHowever,maboutm5myearsmagomshemwasmridingmhermbike,mwentmdownmamrampmandmflippedmheadmfirstm
overmthemhandlembarsmofmthembike.mAtmwhichmtimemshemexperiencedmthismsamemlowmbackmpain,mwentmtomthemERma
ndmhadmX-
raysmthatmshowedmsomeminflammationmandmswelling.mShemwasmthenmprescribedmammusclemrelaxant,mIbuprofen,ma
ndmphysicalmtherapymform8mweeks,mwhichmhelpedmtremendously.mAtmtoday’smvisit,mshemhopesmtomfindmoutmwherem
thempainmismcomingmfrommandmwhatmshemcanmdomtompreventmitmfrommreturning.
PastmMedicalmHistory:
• Depression-active-mdiagnosedm6myearsmagomaftermmommpassedminmamMVAm•
Low
m backmpain-active-diagnosedmaboutm5myearsmagomaftermpreviousmbackminjury.
,PastmSurgicalmHistory:
• Nomsurgeriesmtomdat
emAllergies:
, NKAmtomfood,mdust,mmold,menvironment,mormmedication
s.mMedications:
Sertralinem150mmgmbymmouthmdailymformdepression
HealthmMaintenance:
• InfluenzamVaccine-Octoberm2017matmCVS.
• Allmothermimmunizationsmaremup-to-datemincludingmTDaP,mMMR,mandmVaricella.
• LastmPapmsmear-mJunem2016-normal
• PerformsmMSBE
• DepressionmscreenmpositivemformPHQ2;monmmedsmandmseemPsychologistsmregularly.
• CAGEm0/4
Personalm&mSocialmHistory:
• Livesmaloneminmamonembedroommapartment.
• WorksmatmamnursingmhomemasmamCertifiedmNursingmAssistantm4mdays/week.mShemlovesm
hermjobmandmhasmamdependablemcar.
• Deniesmanymsmoking,millicitmdrugmabuse,mormalcoholmmisuse.
• Previouslymdidmcrossmfitminmhighmschool.mHowever,mdomtomworkmshemhasn’tmhadmm
uchmtimemtomgetmthemamountmofmexercisemshemneeds.
• Patientmismsexuallymactivemwithmonlymonemsexmpartner,mhermboyfriend.
• 24mhourmdietmrecall:mB-monembowlmofmChexmcereal;mL-
mamturkeymsandwich,mchips,mandmamdietmcoke;mS-aboutm1-2mcupsmofmcheese-
itmcrackersmandmamdietmcoke;mD-
mMeatloaf,mveggies,mmashedmpotatoesm frommBostonm Market,mandmambottledmwater.
FamilymHistory:
Grandparents
Paternal:
Paternalmgrandfatherm81,mHTN,mDM;mPaternalmgrandmotherm76mhistorymofmD
MmandmMI.
Maternal:
Maternalmgrandfathermdiedmatm82mfrommMI,mmaternalmgrandmotherm7
9,mhistorymofmdiabetesmandmarthritis.
m m
Tina Williams “Acute Low Back Pain”iHuman
m m m m m
Tina Williams " Acute Low Back Pain" iHuman
m m m m m m m
History & Physical Examination
m m m
SOAPm#4 2
PatientmDemographics:
Name:mT.H.
Age/race/sex:m26mHispanicmFemale
Clinicalmsite:mPrimarymCaremclinic;mPresentsmformsickmvisit.
SUBJECTIVE DATA m
ChiefmComplaintsm:m“Mymlowermbackmhasmbeenmhurtingmformaboutm2mweeksmnow”.
HistorymofmPresentmIllnessm:
Mrs.mHmismam26my/omHispanicmfemalemwithmamsixmyearmhistorymofmdepression-
controlledmonmSertraline,mwhompresentsmtomthemclinicmtodaymcomplainingmofmspontaneousmoccurrin
gmacutemlowmbackmpainmtomlumbermregionmthatmstartedmaboutm2mweeksmagomaftermwearingmheelsmtom
amparty.mReportsmitmhasmbeenmverymdifficultmtomdressmlowermbodymandmtombend.mShemreportsmthempai
nmismconstantmbutmhasmintermittentmintensitiesmofmachingmandmsorenessmthroughoutmthemday.mThemp
ainmismlocalizedmtomthemlumbermarea,mdescribedmasmachingmandmsorenessmwithmnomradiation,mratedma
m5/10minmofficemtodaymwithm3/10mbeingmthemlowestmamountmofmpainmexperiencedmandm8/10mbeingmth
emworstmpainmshemhasmexperienced.mReportsmthempainmismworseminmthemmorningsmwhenmgettingmoutm
ofmbedmaftermlyingmdownmallmnight.mShemhasn’tmtriedmanympharmacologicalmormnon-
pharmacologicalmtherapies.mShemreportsmnomheavymlifting,mstrenuousmexercise,mcurrentminjuries,mno
rmfeelingsmofmanxietymor
depression.mHowever,maboutm5myearsmagomshemwasmridingmhermbike,mwentmdownmamrampmandmflippedmheadmfirstm
overmthemhandlembarsmofmthembike.mAtmwhichmtimemshemexperiencedmthismsamemlowmbackmpain,mwentmtomthemERma
ndmhadmX-
raysmthatmshowedmsomeminflammationmandmswelling.mShemwasmthenmprescribedmammusclemrelaxant,mIbuprofen,ma
ndmphysicalmtherapymform8mweeks,mwhichmhelpedmtremendously.mAtmtoday’smvisit,mshemhopesmtomfindmoutmwherem
thempainmismcomingmfrommandmwhatmshemcanmdomtompreventmitmfrommreturning.
PastmMedicalmHistory:
• Depression-active-mdiagnosedm6myearsmagomaftermmommpassedminmamMVAm•
Low
m backmpain-active-diagnosedmaboutm5myearsmagomaftermpreviousmbackminjury.
,PastmSurgicalmHistory:
• Nomsurgeriesmtomdat
emAllergies:
, NKAmtomfood,mdust,mmold,menvironment,mormmedication
s.mMedications:
Sertralinem150mmgmbymmouthmdailymformdepression
HealthmMaintenance:
• InfluenzamVaccine-Octoberm2017matmCVS.
• Allmothermimmunizationsmaremup-to-datemincludingmTDaP,mMMR,mandmVaricella.
• LastmPapmsmear-mJunem2016-normal
• PerformsmMSBE
• DepressionmscreenmpositivemformPHQ2;monmmedsmandmseemPsychologistsmregularly.
• CAGEm0/4
Personalm&mSocialmHistory:
• Livesmaloneminmamonembedroommapartment.
• WorksmatmamnursingmhomemasmamCertifiedmNursingmAssistantm4mdays/week.mShemlovesm
hermjobmandmhasmamdependablemcar.
• Deniesmanymsmoking,millicitmdrugmabuse,mormalcoholmmisuse.
• Previouslymdidmcrossmfitminmhighmschool.mHowever,mdomtomworkmshemhasn’tmhadmm
uchmtimemtomgetmthemamountmofmexercisemshemneeds.
• Patientmismsexuallymactivemwithmonlymonemsexmpartner,mhermboyfriend.
• 24mhourmdietmrecall:mB-monembowlmofmChexmcereal;mL-
mamturkeymsandwich,mchips,mandmamdietmcoke;mS-aboutm1-2mcupsmofmcheese-
itmcrackersmandmamdietmcoke;mD-
mMeatloaf,mveggies,mmashedmpotatoesm frommBostonm Market,mandmambottledmwater.
FamilymHistory:
Grandparents
Paternal:
Paternalmgrandfatherm81,mHTN,mDM;mPaternalmgrandmotherm76mhistorymofmD
MmandmMI.
Maternal:
Maternalmgrandfathermdiedmatm82mfrommMI,mmaternalmgrandmotherm7
9,mhistorymofmdiabetesmandmarthritis.
