SOAP NOTE Lumbar Pain

SOAP NOTE Name: S.N. Date: 4/18/2016 Time: 15:20 ID # Age: 75 Sex: Male 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, pneumonia hx, TB Eyes Corrective lenses Gastrointestinal Constipation Ears Denies ear pain, hearing loss, ringing in ears, or discharge Genitourinary/Gynecological Denies urgency, frequency burning, or change in color of urine. Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Low back pain that is exacerbated with active and passive movements. Breast Denies lumps. Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight 210 BMI 32 Temp 98.4 BP 145/ 91 Height 5’5 Pulse 74 Resp 14 General Appearance Healthy appearing adult male in no acute distress. Well groomed, alert and oriented x3 that answers all questions appropriately and make eye contact. The patient denies any fever or chills Skin Skin is white, warm, dry, clean and intact. No cyanosis rashes or lesions noted. Pelvic scar for cesarean sections HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is no erythematous and without exudate. Teeth are in good repair. Cardiovascular Regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. Pedal edema bilateral. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen protuberant. BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Deferred. Genitourinary Bladder is non-distended. External genitalia deferred. Musculoskeletal Straight right leg raising sign positive. Dorsiflexion of R ankle is positive. Light loss of sensation in R leg. Decreased muscle strength in R leg and weakness. Neurological Speech clear. Good tone. Unstable gait. Numbness in R lower extremity. Psychiatric Alert and oriented x3. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Compressive metabolic panel, CBC w Diff, Lipid Panel, lumbar x-ray was indicated today. Patient blood exam was sent to the lab pending results. Special Tests Ct scan. Diagnosis Diagnosis Essential Hypertension Obesity. Lumbosacral strain Differential Diagnoses  Sciatica of unknown etiology.  Herniated disk  Compression fracture  Neoplasm of spine. o I10-Esential Hypertension Presumptive Diagnosis o Lumbosacral strain Plan/Therapeutics Plan: Medication: • Diovan HTC 80/12.5 mg po daily • Amlodipine 10 mg po daily D/C (presumptive ADR) • NSAIDs as needed: Naproxen (Naprosyn) 500 mg initially, followed by 250 mg every 6 to 8 hours. 2. Acetaminophen may also be used as needed, especially if the patient is not able to tolerate ibuprofen. 3. For more severe pain not relieved by NSAIDs, consider acetaminophen (Tylenol) with codeine for short duration. Narcotics should not be used for more than 2 weeks. 4. Muscle relaxants: Muscle relaxants should not be used for more than 2 weeks. a. Cyclobenzaprine (Flexeril) 10 mg one to three times daily. Non-medication treatments and education Step 1 (2–4 days): a. Bed rest for severe radiculopathy only. b. Limit walking and standing to 30 to 40 minutes each day. c. Recommend application of heat or cold packs to site as needed. Step 2 (7–14 days): a. Reevaluate neurologic and back exam; tell the patient “Let pain be your guide” when resuming normal daily activities. b. Have patient perform gentle stretching exercises. c. Encourage walking on flat surfaces. d. Educate patient regarding proper care of the back, with regard to exercises, posture, and so forth. e. Provide handouts on back exercises/stretches for the patient. f. Physical therapy may be implemented at this time if no significant improvement is noted. Step 3 (2–3 weeks) a. Reevaluate the patient, noting degree of improvement with exam. Continue muscle toning and reconditioning exercises. Follow-Up: In 1 to 2 weeks. Consultation/Referral A. If cauda equina syndrome is suspected, prompt referral to a physician is necessary. B. If pain is severe enough that narcotics are needed, consult with a physician. C. If bilateral sciatica is associated with vertebral collapse, osteoporosis, neoplasia, and/or vascular disease, consult with a physician. Reference Cash J. C. & Glass, C.A., (2014). Family Practice Guidelines, Third Edition, 3rd Edition. [VitalSource Bookshelf Online]. Retrieved from FDA. (2015). Norvasc. Retrieved from Woo T. M., & Wynne, A. L. (2011). Pharmacotherapeutics for nurse practitioner prescribers. Philadelphia, PA: F.A. Davis Co. Evaluation of patient encounter The evaluation of this patient was very useful for me my learning in the diagnosis and management of low back pain