Focused SOAP Note on Back Pain Essay

Focused SOAP Note on Back Pain Essay

Focused SOAP Note on Back Pain Essay

Focused SOAP Note on Back Pain
Patient Information:
Patient Initials: M. J Age: 42 Gender: Male Race: African American
Subjective Data:
Chief Complaint (CC): The patient reports experiencing pain in his lower back for the past month. He also reports that the pain sometimes radiates to his left leg.

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History of Present Illness (HPI):
Mr. M. J, a 42-year-old African American male, presents with complaints of lower back pain that started a month ago. He describes the pain as a constant, dull ache with an intermittent sharp pain that radiates down his left leg. The pain is exacerbated by prolonged sitting and standing and relieved by lying down. He reports experiencing numbness and tingling in his left leg, which worsens with prolonged standing or walking. He denies any recent history of trauma or injury to the back. The pain is rated as 8/10 on the pain scale, and it has been affecting his daily activities and quality of life. He reports taking over-the-counter pain medications, which provide minimal relief. There is no history of fever, chills, or night sweats. He denies any urinary or bowel incontinence or difficulty with urination.
Current Medications:
The patient has used naproxen 750mg PO q12hr PRN for two weeks to manage the pain.
Allergies:
No known drug or food allergy.
Past Medical History (PMHx):
The patient’s medical history includes undergoing corrective surgery for spinal stenosis three years ago, being admitted in March 2020 due to Covid-19 infection, and being compliant with all immunizations. The last one is the Covid-19 vaccine booster he received in January of this year.
Social History (Soc Hx):
Mr. M. J is a software engineer employed by a tech company who lives with his wife and is expecting their second child. They reside in a safe neighborhood with a well-functioning transportation system, minimal health risks, and financial stability. Their modern apartment is equipped with contemporary technology, such as smoke detectors. He takes necessary precautions while driving, such as avoiding using his cell phone and abstaining from driving under the influence of alcohol. Although he denies smoking tobacco, he does consume alcohol occasionally during special events, such as birthdays and anniversaries. Mr. M. J enjoys the support of his colleagues at work and occasionally receives visits from his parents, which contributes to his strong support system.
Family History Fam Hx:
Mr. M. J is the second born in a family of three, and his elder sister has been diagnosed with osteoarthritis and is receiving treatment, while his other siblings are alive and healthy; furthermore, his mother is undergoing treatment for degenerative disc disease and his father is receiving treatment for osteoarthritis.

Review of Systems (ROS):
General Appearance:
Mr. M.J. is an African American male who is well-groomed and kempt. He weighs 80 kilograms and reports no weight loss. He is well nourished with no scars on his face. He looks worried and appears to be in pain.
HEENT:
Eyes: He does not experience any symptoms of vision loss, such as blurred vision, double vision, painful eyes, or yellowing of the sclera.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. He has not had any recent episodes of epistaxis and has no nasal polyps or recent sinus infections. He has had no difficulty chewing or swallowing, no gingivitis or bleeding gums.
Skin: He has a surgical scar on his back. No rash or itching, and hair is well distributed with no hair loss. The nails are intact with no clubbing.
Cardiovascular: No chest discomfort, palpitations, history of murmurs, or lower limb edema. Capillary refill time is less than 2 seconds.
Respiratory: No shortness of breath, cough, or sputum
Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
Genitourinary: No urinary or bowel incontinence or difficulty with urination.
Neurological: No headache, dizziness, or syncope. Reports numbness and tingling in the left leg. No change in bowel or bladder control.
Musculoskeletal: lower back pain that radiates down his left leg.
Hematological: No bruising, bleeding, or anemia.
Lymphatics: Enlarged lymph nodes.
Psychiatric: No history of mental illnesses such as depression or anxiety.
Endocrinology: No cold or heat intolerance, no polyuria or polydipsia.
Allergies: No known allergies, no history of rhinitis, hives, or asthma
Objective Data:
Vital Signs: B/P: 118/74mmHg, P-72b/min, T- 98.5F, RR- 16b/min, Weight- 80 kg.
Musculoskeletal: Decreased range of motion, muscle weakness, muscle tenderness, numbness and tingling and reflex changes.
Neurological: All cranial nerves intact. Lasegue test for Lumber 4 nerve, crossed straight leg test for Lumbar 5 nerve and heel walk test for sacral nerve 1 are all positive.
Skin/Lymph nodes: Inguinal lymph nodes palpable.
Diagnostic results: MRI, CT scan, and X-ray
Assessment:
Differential Diagnoses:
1. Lumbar spinal stenosis
2. Degenerative disc disease
3. Osteoarthritis
4. Lumbar disc herniation
5. Ankylosing spondylitis
6. Sacroiliac joint dysfunction.
The patient’s chief complaint of lower back pain with radiation to the left leg is a common symptom in many musculoskeletal disorders. The differential diagnoses listed indicate possible causes of the patient’s pain, including lumbar spinal stenosis, degenerative disc disease, osteoarthritis, lumbar disc herniation, ankylosing spondylitis, and sacroiliac joint dysfunction. These conditions are often characterized by inflammation, compression, or degeneration of the spinal structures, leading to nerve root impingement, muscle spasms, and pain (Wu et al., 2020).
Mr. M.J., a patient with a surgical history of spinal stenosis, presents with lower back pain radiating down his left leg, accompanied by numbness and tingling in his left leg. This suggests a possible defect in the L4, L5, and S1 nerve roots, which can be confirmed with recommended tests such as the Lasegue test for Lumber 4 nerve, crossed straight leg test for the Lumbar 5 nerve, and heel walk test for the sacral nerve 1 (Camino & Piuzzi, 2021). Other symptoms, such as weakness in the lower extremities, loss of reflexes, decreased range of motion, muscle tenderness, numbness and tingling, should also be explored to rule out more severe conditions. The clinician should consider the patient’s history, physical examination, and diagnostic tests to narrow down the differential diagnoses.
Different diagnostic tests can differentiate between conditions, such as an MRI scan for lumbar disc herniation and spinal stenosis and X-rays for spondylolisthesis and degenerative disc disease (Kim et al., 2020). Based on the patient’s symptoms and history, the presence of previous corrective surgery for spinal stenosis and a family history of degenerative disc disease and osteoarthritis increases the likelihood of spinal stenosis and degenerative disc disease being the cause of the pain (Wu et al., 2020). However, further examination and testing are necessary to make a definitive diagnosis.

References
Camino, G. O., & Piuzzi, N. S. (2021). Straight leg raise test. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539717/#:
Kim, G. U., Chang, M. C., Kim, T. U., & Lee, G. W. (2020). Diagnostic Modality in Spine Disease: A Review. Asian Spine Journal, 14(6), 910–920. https://doi.org/10.31616/asj.2020.0593
Wu, P. H., Kim, H. S., & Jang, I.-T. (2020). Intervertebral disc diseases PART 2: Review the current diagnostic and treatment strategies for intervertebral disc disease. International Journal of Molecular Sciences, 21(6), 2135. https://doi.org/10.3390/ijms21062135

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By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

Review the following case studies:

Case 1: Back Pain

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

references

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

Chapter 13, “The Spine, Pelvis, and Extremities”

In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., . . . Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions.Links to an external site. The Lancet, 391(10137), 2368–2383. https://doi.org/10.1016/s0140-6736(18)30489-6

Hicks, C., Levinger, P., Menant, J. C., Lord, S. R., Sachdev, P. S., Brodaty, H., & Sturnieks, D. L. (2020). Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people.Links to an external site. BMC Geriatrics, 20(1), 94. https://doi.org/10.1186/s12877-020-1487-2