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SOAP Note for A 33-year-old Hispanic female click here for assignment
SOAP Note for A 33-year-old Hispanic female (Bickley, 2007)
A 33-year-old Hispanic female presenting today with lower back pain x 2 days. She called this morning saying she needed to be seen because she was in so much pain that she could not work and needed a work excuse.
CC: “My back hurts”.
HPI: Pain started yesterday while at work. Last night she went to sleep as usual, when she woke up this morning she was in a lot of pain and was very stiff. The pain is described as a 7/10 on the pain scale, feels like burning. Pt states pain is worse in the R lumbo-sacral area. Pain radiated to her R buttock. It hurts her to stand up or find a comfortable position. Pain worsens after bending or lifting. Her back hurts even at rest, but gets worse with movement. Taking Tylenol 500mg 2 caplets with no relief of the pain. No hx of UTI symptoms; no vaginal discharge or dyspareunia; no change in bladder or bowel habits; denies weight loss or fever. No hx of previous back pain, injury or trauma. Pt states she works as a cashier at the grocery store where she stands most of the day. Yesterday was her second day of working over time at work. Denies muscle weakness, paresthesia, loss of sensations, and no severe or progressive neurological deficit in lower extremity.
PMH:
Medical Hx: HTN (2006), Type 2 NIDDM (2007)
Surgical Hx: Appendectomy (2001)
Medications: Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for back pain with no relief
Allergies: NKA to food or medications
FAMILY HISTORY:
SOAP Note for A 33-year-old Hispanic female
Social History(SOAP Note for A 33-year-old Hispanic female)
General: Born and raised in Cali, Colombia, moved to the US with her parents when she was 17 years old.
Marital status: Single Mom of a 4-yr/old girl. Ex-husband not involved financially or physically in care of child.
Living situation: Parents live 100 miles away. One brother in town; sees brother seldom. Mrs. B has a few close friends. Pt sates she is in debt “way over head”. No health insurance benefits. Considers herself a strong and independent woman.
Children: One 4-yr/old daughter who is healthy
Occupation: Works at a local grocery store as a cashier. She stands most of the day in her job. Sees job only as a means of providing income for her and her daughter.
Leisure Patterns: Pt states she doesn’t have time to “relax”.
Social habits: Denies smoking or alcohol consumption. Does not exercise.Read more
Spirituality: No church involvement but states that she believes in God.
Nutrition: Pt states her appetite has increased owing to “stress”, craves chocolate, eats what she wants, no special diet. Has not experienced any changes on her weight.
Sleep Patterns: States that she usually gets about 7 hrs of sleep every night.
REVIEW OF SYSTEMS (Bickley, 2007)
SOAP Note for A 33-year-old Hispanic female
General: States there have not been any changes in the past 5 years. He has been wearing the same size of clothes for the past 5 years. Denies weakness, fatigue, or fever.
Skin: Reports dryness of the skin, especially on his hands, legs and feet. Denies rashes, lumps, sores, itching, and changes in color. Denies changes in his nails or hair. Denies changes in size or color of moles.
HEENT: Head: Denies headache, head injury, dizziness, or lightheadedness. Eyes: Denies any changes in her vision. Does not use glasses. Last eye exam 2 years ago (Oct/06). Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma or cataracts. Ears: States she doesn’t have any hearing problems. Denies tinnitus, vertigo, earaches, infection, or discharge. Denies use of hearing aides. Nose and Sinuses: Pt states she gets occasional allergies and colds that cause her to have stuffiness and discharge. Denies hay fever, nose bleeding, or sinus trouble. Throat: States her teeth are yellow and sometimes her gums would bleed. Denies use of dentures. Last dental examination 2 yrs ago (Oct/06). Denies sore tongue, frequent sore throats or hoarseness. Denies having dry mouth or excessive thirst.
Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.
Breasts: Denies lumps, pain, discomfort or nipple discharge.
Respiratory: Denies cough, sputum, hemoptysis, dyspnea, wheezing, or pleurisy. Has not had a Chest X Ray done. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis.
Cardiovascular: Denies any troubles with her heart, HBP, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Has never had EKG done.
Gastrointestinal: Denies trouble swallowing, heartburn, changes in appetite, or nausea. States she has bowel movements every other day normally, the stools are small, brown and formed. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble. Denies Hepatitis. Does not remember if she has received Hep B vaccine.
Urinary: Goes to the bathroom 4 or 5 times a day. Denies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.
Genital: Menarche at age 13. States she gets her period approx. q 28 days and it lasts about 5 days. Flow heavier on the first 2 days. Denies bleeding between periods. LMP: September 4th. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G1 P1, spontaneous vaginal delivery at 39 weeks. Denies any complications with her pregnancy. Denies use of birth control methods. Not sexually active at the moment. Has had one partner in the past 5 years. Denies exposure to HIV infection or STDs.
Periferal Vascular: Pt states she has a few spider veins that look like bruises, she got them during the pregnancy. Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet. Pt states there have not been any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness.
Musculoskeletal: Denies muscle weakness, paresthesia, loss of sensations, no severe or progressive neurological deficit in lower extremity. No Hx of cancer, or risk factors for spinal infection (no IV drug abuse, UTI, Immune suppression). Pt reports feeling lower back pain that started yesterday while at work that is worse in the R lumbo-sacral area. Pain radiates to her R buttock. Pt states it hurts to stand up or find a comfortable position. States her back hurts even at rest, but pain gets worse when she moves. Pain worsens after bending or lifting. Denies other muscle or joint pain, stiffness, arthritis or hx of gout. Denies fever, chills, rash, anorexia, weight loss or weakness.
Psychiatric: Denies nervousness, tension, mood changes, depression, or memory changes.
Neurologic: Denies changes in mood, attention or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.
Hematologic: Denies anemia, easy bruising or bleeding, and past transfusions.
Endocrine: Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.
OBJECTIVE DATA: (Bickley, 2007)
Vital signs: T: (oral) 98º; P: 86; R: 20; BP: 114/74; Ht: 67”, Weight: 120 lb (BMI: )
General: Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.
Physical Examination findings
Skin: Skin is warm, pink and supple, no lesions noted.
HEENT: Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits.
Lungs: Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or ronchi.
Cardiovascular: Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostals space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ , brisk, and symmetric.
Breasts: Deferred
Abdomen: Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.
Genitalia: Deferred
Rectal: Deferred
Musculoskeletal: No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees and ankles. Gait/Posture: Flexed forward at 15º, walked slowly with a wide based stance, and grimaced with movement. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis; unable to extend or rotate. Lateral movement: bilaterally to 20º. All attempts at ROM produced pain. Right paravertebral muscle spasm noted in lumbar area. Straight leg raise (SLR) negative, Patrick test negative, crossed SLR negative. No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.
Neurologic: Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time. Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going.
ASSESSMENT: (Uphold & Graham, 2003)
SOAP Note for A 33-year-old Hispanic female
Diagnosis:
- Acute lumbosacral strain (M54.5)
Differentials:
- Acute lumbosacral pain (M54.5): Minimal discomfort initially followed by increased pain and stiffness 12-36 hrs later, SLR, crossed SLR, heel and toe walking were intact. No muscular weakness or loss of sensation. DTRs were equal and not depressed. Babinski negative. Spasm noted in paravertebral muscles.
- Herniated lumbar disc (M51.2): Pain in buttocks.
- Sciatica (M54.3): Pain in back/buttocks.
- Possible vertebral Fx (S32.009A): Low back pain.
PLAN: (Uphold & Graham, 2003)
Diagnostic: No tests needed at this time
Therapeutic: Pharmacological:
Continue to take Tylenol 650 mg po q 4-6 hrs around the clock for pain for 3 to 7 days
Alternate with Naproxen 500mg po bid prn for pain for 3 to 7 days (Wait 2-3 hrs between medications, do not take together).
Non-pharmacological:
Local application of ice may help initially to decrease pain. After 2-3 days, either heat or ice may be applied. No bed rest indicated. Take 3-7 days off work (her job would increase stress on her back), or perform other duties until the symptoms abate.
Patient Education:
- Avoid jerky, hurried movements when lifting
- Lift with legs by straddling the load; bend knees to pick up load; keep back straight (do not bend back)
- Keep objects close to the body at navel level when lifting
- Avoid twisting, bending, reaching while lifting
- Avoid prolonged sitting
- Change positions often while sitting
- A soft support belt for the back, armrests to support some body weight, a slight reclining chair may make sitting more comfortable
- Firm mattress/bed board, lying supine with hips and knees flexed on pillows is beneficial when sleeping
- May return to work in 4-8 days
- As soon as she returns to regular activities (in 2 weeks), aerobic conditioning exercises such as walking, swimming, stationary biking, or even light jogging may be recommended to avoid debilitation.
Referral: None
Follow-Up: Come back if the pain does not improve in 24-48 hrs. Return to the office in 7-10 days. Return sooner if neurological symptoms worsen or bowel/bladder dysfunction occurs.
Evidence Based Practice: (National Guideline Clearinghouse, 2008
Acute lumbar strain is self-limited low back pain associated with muscle spasm with limitation of motion of varying severity. This is usually brought on by some type of sudden overexertion while lifting, bending, straining, or abrupt movement. The symptoms may occur immediately or develop over the course of a day as muscle spasm increases. In the absence of fracture or herniated disc, symptoms subside gradually in days or weeks.
National Guideline Clearinghouse:
Reassure patient that 90% of episodes resolve within six weeks regardless of treatment. Advise that minor flare-ups may occur in the subsequent year.
Therapy
- Stay active and continue ordinary activity within the limits permitted by pain. Avoid bedrest. Early return to work is associated with less disability.
- Injury prevention (e.g., use of proper body mechanics, safe back exercises)
- Recommend ice for painful areas and stretching exercises.
- McKenzie exercises are helpful for pain radiating below the knee.
Referral
- If no improvement at 1 to 2 weeks, refer for goal-directed manual physical therapy, not modalities such as heat, traction, ultrasound, transcutaneous electrical nerve stimulation (TENS).
- Surgical referral usually not required if no “red flags.”
Medication Strategies
- Medication treatment depending on pain severity with acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
- COX-2 inhibitors and muscle relaxants have not been shown to be more effective than NSAIDs
- Opiate analgesics have not been shown to be more effective than NSAIDS in acute low back pain.
Testing
- Diagnostic tests or imaging usually not required.
- If no improvement after 6 weeks, consider imaging