Focused SOAP Note- Case Study Low back pain Essay

Jensen Dockendorf
Case Study 1- Back pain SOAP
COLLAPSE
Episodic/Focused SOAP Note- Case Study 1 Low back pain

Patient Information:

Patient: AB Age: 42 Sex: Male Race: Caucasian

S.

CC: ‘Low back pain”

HPI: 42 year-old Caucasian male reports lower back pain that has started a month ago. The pain is sharp and radiates down his left leg. Patient denies any associated symptoms. The patient states that the pain starts after sitting for long periods of time or lifting heavy objects. After taking Ibuprofen 400mg PO PRN, the pain is tolerable but still existent. Patient rates his pain a 8/10. Focused SOAP Note- Case Study Low back pain Essay

Current Medications:

Ibuprofen 400mg PO PRN for pain
Omeprazole 20mg PO qd for GERD
Albuterol 90 mcg Inhalation PRN
Allergies:

NKDA
No seasonal allergies
No food allergies
PMHx:

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Immunization Status: Up to date on all immunizations, last Tdap: 5/7/2022

GERD, Exercise- induced asthma

No surgical history

Soc Hx:

Occupation: Welder
Married with 1 son Focused SOAP Note- Case Study Low back pain Essay
Denies alcohol use
Denies tobacco use
Denies illicit drug use such as marijuana or cocaine
Lives in a private family residence
Fam Hx:

Mother: alive and well, age 67
Father: HTN, HLD, age 70
Maternal grandmother: Diabetes, age 87
Maternal grandfather: Deceased, heart attack, age 86
Paternal grandmother: Deceased, natural causes, age 75
Paternal grandfather: Deceased, stroke, age 76
Son: alive and well, age 16
General: Denies weight loss, fever, chills, weakness or fatigue. Focused SOAP Note- Case Study Low back pain Essay

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.

Cardiovascular: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

Respiratory: Denies shortness of breath, cough or sputum.

Musculoskeletal: reports 8/10 low back pain that radiates to left leg Focused SOAP Note- Case Study Low back pain Essay

O.

Physical exam:

Vital signs:

BP: 128/80
HR: 86 bpm
RR: 18
Temp: 37.2 C
O2 SAT: 98%
Ht: 6’1”
Wt: 190
General: Patient is alert & oriented, steady gait, well dressed, proper hygiene, expected facial expressions, normal affect Focused SOAP Note- Case Study Low back pain Essay

HEENT:

EYES: No abnormal findings, White sclera, conjunctiva moist and pink, no conjunctival discharge
EARS: Pink canal, pearly gray membrane, no visible abnormal findings, no discharge
NOSE: Erythemic in color, clear discharge, decreased patency, no visible abnormal findings
NECK: symmetrical, no abnormal findings
MOUTH AND THROAT: Moist and pink mucosa, edematous tonsils, erythemic posterior oropharynx color, cobblestone texture. No postnasal drop
SINUSES: No tenderness reported Focused SOAP Note- Case Study Low back pain Essay
Respiratory:

FREMITUS: Equal bilaterally, expected fremitus
LUNGS: Breath sounds present in all areas, no adventitious sounds, all areas clear
BRONCHOPHONY: Negative
Cardiology:

HEART SOUNDS: S1 and S2 audible, no extra sounds noted
CHEST WALL: all areas resonant, no areas of dullness
Musculoskeletal:

Lower back pain that radiates to left lower extremity
No evidence of trauma
Pain increased with flexion, extension and twisting Focused SOAP Note- Case Study Low back pain Essay
Decreased mobility due to pain
Diagnostic results:
Lasegue’s sign
This test is reveals lumbosacral radicular irritation and it is positive when the pain is induced before the leg is raised up to the minimal of 45 degrees from laying supine (Kamath & Kamath, 2017)
Slump test
The patient is seated upright with hands behind their back, and they are instructed to bend forward at the hip. The patient’s neck is bent down with the chin touching their chest and the patient attempts to extend on leg to a degree possible (Hochschuler, 2019). Focused SOAP Note- Case Study Low back pain Essay
MRI
This test allows the provider to see the nerves, surrounding tissues and facet joint capsules (Hochschuler, 2019).
Discogram
This study allows the provider to determine abnormalities in the intervertebral discs but injecting contrast dye (Hochschuler, 2019).
Diagnostic Nerve Block Injections
This nerve block solidifies pain caused by conditions such as sciatica because if the pain is relived with an anesthetic injection around that nerve, it confirms the cause (Hochschuler, 2019). Focused SOAP Note- Case Study Low back pain Essay

A.

Differential Diagnoses (DDx):

Sciatica
Sciatica is the primary diagnosis for this patient due to his reporting of the symptoms involving low back pain and pain that radiates down his left leg. According to Hospital of Special Surgery (n.d.), the first symptom of this condition is lower back pain that radiates down on lower extremity. The Sciatic nerve is the largest nerve in the body and can be easily irritated.

Spinal stenosis
Spinal stenosis is a condition that can occur over time due to wear and tear. This patient does not describe any repetitive activities that would induce this condition and his age is not appropriate to assume that it is a natural progression. Johns Hopkins Medicine (n.d.) explains that the narrowing of the spine can cause pressure on the spinal cord which results in pain of the muscles that are affected by the nerves. This patient is dealing with nerve pain but not related to this condition. Focused SOAP Note- Case Study Low back pain Essay

Ankylosing Spondylitis
Ankylosing Spondylitis is an autoimmune condition that creates back pain but not in your typical form. Dan Kiefer (2021) explains that AS typically results in back pain at rest, particularly when first getting up in the morning as well as exercise actually helping the condition instead of making it worse. This patient explains that his pain occurs when seated for a long period of time but also increases with exercise or weightlifting. Keifer (2021) continues to explain that this condition is not typical in younger patients. Focused SOAP Note- Case Study Low back pain Essay

Herniated Disc
A herniated disc is typically due to an injury or an early stage of degeneration, according to the American Association of Neurological Surgeons (n.d.). The displacement on of the disc can put pressure on the nerves when the injury is in the lower back causing low back pain and pain that can radiate to the lower extremities.

Muscle strain
A muscle strain is a result of an injury that can then be the most common cause of back pain. According to the American Association of Neurological Surgeons (n.d.), a muscle strain is highly typical in the lower back because of its support of upper body weight and perform moving, twisting and bending. Focused SOAP Note- Case Study Low back pain Essay

References

American Association of Neurological Surgeons. (n.d.). Herniated disc. AANS. Retrieved July 20, 2022, from https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc#:~:text=A%20herniated%20disc%20(also%20called,an%20early%20stage%20of%20degeneration. Focused SOAP Note- Case Study Low back pain Essay

American Association of Neurological Surgeons. (n.d.). Low back strain and Sprain. AANS. Retrieved July 20, 2022, from https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Low-Back-Strain-and-Sprain

Hochschuler, S. (2019). Diagnosing the cause of sciatica. Spine. Retrieved July 20, 2022, from https://www.spine-health.com/conditions/sciatica/diagnosing-cause-sciatica

Kamath, S. U., & Kamath, S. S. (2017). Lasègue’s Sign. Journal of clinical and diagnostic research : JCDR, 11(5), RG01–RG02. https://doi.org/10.7860/JCDR/2017/24899.9794

Kiefer, D. (2021, February 5). 5 warning signs of ankylosing spondylitis. Healthline. Retrieved July 20, 2022, from https://www.healthline.com/health/ankylosing-spondylitis/warning-signs

Johns Hopkins Medicine. (2022, February 15). Lumbar spinal stenosis. Johns Hopkins Medicine. Retrieved July 20, 2022, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/lumbar-spinal-stenosis

Sciatica / sciatic nerve pain: Causes, symptoms, treatments. Hospital for Special Surgery. (n.d.). Retrieved July 20, 2022, from https://www.hss.edu/condition-list_sciatica.asp Focused SOAP Note- Case Study Low back pain Essay