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NURS 6512 Week 8 discussion, Low Back Pain Episodic/Focused SOAP Note

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NURS 6512 Week 8 discussion, Low Back Pain Episodic/Focused SOAP Note. Patient Information: M.J. 42-year-old Caucasian Male SUBJECTIVE CC: Low back pain HPI: 42-year-old Caucasian male patien ... t with no significant health history presenting with lower back pain. The pain began 1 month ago, it is located in the lower back and sometimes radiates to the left leg, it is constant, he describes the pain as dull and achy, it is alleviated by laying supine, and is aggravated by standing for prolonged periods and bending or twisting, he reports taking NSAIDs which provide temporary relief, he rates his pain 8/10. Medications: No prescription medication. OTC Ibuprofen 200 mg orally PRN for pain. Last dose ibuprofen was this morning at 8 am. Allergies: NKDA PMHx: No significant diseases or illnesses. No previous hospitalizations. Reports good appetite. Sleeps well usually, but recently back pain has prevented him from getting good sleep. Up to date on immunizations. Influenza vaccine received this season. Soc Hx: M.J. is a general contractor and owns his own business, his company specializes in home renovations. He is married for 15 years and has 2 children ages 13 and 10. He enjoys hiking, surfing, and skiing with his family. He quit smoking 10 years ago, and reports drinking alcohol on rare occasions. He denies illicit drug use. He reports a healthy lifestyle including lifting weights 3 times a week, and eating a high protein and low carb diet. Fam Hx: Mother age 68 with hypothyroidism. Father age 72 with HTN and DM 2. Grandparents deceased, reasons unknown. Has two siblings ages 45 and 38, with no illnesses. Children in good health as well. [Show More]

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