SOAP Note for Chronic Lower Back Pain

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SOAP-chronic lower back pain Assignment 4.1: SOAP Note for Chronic Lower Back Pain Treva Risher Bradley University, Peoria, Illinois SOAP Note for Chronic Lower Back Pain SUBJECTIVE CC: ... M.W. is a 47 year old female patient complaining of lower back pain HPI: D.W.. is 72 year old Caucasian male presenting with complaint of chronic lower back pain (rated 7/10 per patient). D.W. states the onset of the pain has been constant but has gotten worse for the past week. He states it is mainly in his lower back, but non-radiating. He describes the pain as dull ache with occasional sharp pain with associated spasms, rates it at a 7/10 with movement, and 4/10 with no movement. He states sometimes he gets worse when he has been working on his daughter’s farm more but his pain only occasionally will stop him from working. He states he take Naproxen in the morning, and then repeats that at night with “some whiskey to help me sleep”, with some relief, but states the pain is just not going away now and “it is slowing me down.” He states he gets approximately six hours of sleep a night, with occasional night terrors. He denies any depression, states he does get lonely at time when thinking about his deceased wife. PMH: Hypertension (HTN), Benign Prostate Hypertrophy (BPH), Myocardial infarction with stent placement to right coronary artery (RCA) in 2019. Low Back Pain. Appendectomy 2000. Pancreatitis 2019. FH: Father (deceased age 62): Colon Cancer. Mother (decreased age 85): Cerebral Vascular Attack (CVA). SH: Lives with his daughter. Widowed: since 2006. Work: Retired Military Diesel Mechanic. Alcohol: nightly, once glass of whiskey. Smoking: Quit 1992 . Illicit drugs: Never. Meds: Atenolol 50 mg orally twice a day, Detrol once daily, Naproxen 240 mg orally twice a day as needed for pain. Allergies: NKDA Immunizations: Up to date ROS: Negative for depression, anxiety, fever, fatigue, dizziness. Negative for weight loss/gain, palpitations, dyspnea, change in appetite, nausea, vomiting, syncope, numbness/tingling. Positive for low back pain, none radiating. OBJECTIVE VS: Temperature: 36.8 C, Respiratory rate: 18, Heart Rate: 67, Blood Pressure 136/62, Oxygen Saturation 96%, Wt. 100 kg, Ht. 162.5 cm, Body Mass Index: kg/m2 General: Well nourished, no acute distress. HEENT: Head: Normocephalic, nontender. Eyes: PERRLA, sclera white, conjunctiva pink. Ears: clean canals bilaterally. Left TM pearly grey with +light reflex and visible bony landmarks. Right TM erythematous and bulging with diminished light reflex, bony landmarks not visualized. No purulent drainage observed. No pain to palpation of mastoid bone. Neck: Supple, no masses, or tender lymphadenopathy. CV: Regular Rate, and Rhythm, Normal S1 S2, no murmurs or gallops Lungs: No respiratory distress. Effort normal. No wheezing, rhonchi, rales. Clear throughout all lung fields. RA saturation is normal at 96%. Abdomen: Soft, nontender, round, nondistended. Bowel sounds present in all 4 quadrants, no hepatosplenomegaly MSK: Full range of motion in all extremities, pain noted with flexion. ASSESSMENT: 1. Chronic lower back pain (Culgin & Duffy, 2017) PLAN: 2. Naproxen (Naprosyn) 220 mg tablet. Take one tablet (220 mg total) orally every 8-12 hours as needed for pain. May take 440 mg once in the first hour if needed. Maximum 600 mg in 24 hours (Drugs, 2019) 3. Metaxalone (Skelaxin) 400 mg tablet. Take one tablet (400 mg total) once at bedtime. May take 1-2 tablets up to four times a day as needed for muscle spasms. (Drugs, 2019) 4. Transcutaneous electrical nerve stimulation (TENS) unit. Electrodes to be place on the low back twice daily as needed for pain. (Culgin & Duffy, 2017) 5. Ice therapy. Place ice to low back 15-20 minutes four times a day as needed for pain. (Culgin & Duffy, 2017) 6. Heat therapy. Please heating pad to low back at low setting for 15 minutes 3-4 times a day as needed for pain. (Culgin & Duffy, 2017) 7. Referral for substance abuse counselor for Alcoholism. (Culgin & Duffy, 2017) 8. Referral for physical therapy for evaluation and treatment of chronic lower back pain. (Culgin & Duffy, 2017) 9. Return to clinic for follow up in 3 months. [Show More]

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