Purdue UniversityMN 576SOAP NOTE LOW BACK PAIN.
Document Content and Description Below
Date and Time of H&P: 5/28/2019, 1:00PM age: 63 DOB: 8/24/1955 Chief Complaint: “I fell two days ago and the left side of my back hurts HPI: Patient is a 63-year-old white Caucasian who presents ... to the clinic with the complaint of having a recent fall two days ago with moderate to severe back pain. Patient states he was walking in his RV and bumped his foot on a shelf and fell. Patient rates pain a 9 on pain scale. Patient describes pain as aching and states when he moves around the pain worsens. Past Medical History: Anxiety D/O F41.9 Other muscle spasm M62.83 Hypercholesterolemia E18.0 I10 Essential HTN Medications: Buspirone 5mg po daily Clotrimazole 1% BID to affected area HCTZ 25mg po daily Iron Ferrous Sulfate 325mg po daily Losartan 50mg po daily Percocet 5-325mg po daily TID as needed Injury: Gun shot wound left leg 1975, work injury to back 1998 Hospitalization/Surgery: 1998 Back surgery, spinal meningitis age 19 Family History: Mother- HTN Immunizations: N/A Allergies: No known drug allergies Social History: Lives alone in a RV Smoking: No Alcohol Use: yes Recreational Drugs: No Occupation: disabled [Show More]
Last updated: 3 years ago
Preview 1 out of 10 pages
Buy this document to get the full access instantly
Instant Download Access after purchase
Buy NowInstant download
We Accept:
Reviews( 0 )
$9.00
Can't find what you want? Try our AI powered Search
Document information
Connected school, study & course
About the document
Uploaded On
Sep 29, 2021
Number of pages
10
Written in
All
Additional information
This document has been written for:
Uploaded
Sep 29, 2021
Downloads
0
Views
169
