Nursing

Nursing

SOAP Note

Subjective

S: John Smith is a 53 y/o AA male. Chief complaint of back pain 8 days ago.

Hxcc: the pain started at the right side of the low bake when the patient was lifting bricks and other heavy objects. He felt pain at low back on the right side. Movement worsens the pain which cannot be treated at home. He has taken Motrin and also used a heating pain to relieve the pain. He did not feel any tingling, numbness, pain radiation from either leg, burning pain. It was the first time he felt any backache

Began 8 days ago when lifting heavy object at work

3-5/10, stabbing and throbbing, over lower back, non-radiating

Worsened by activity, bettered by Icy-Hot

No meds attempted

Denies f/c/n/v, denies dysuria, urinary incontinence, leg weakness

This is the first occurrence; he believes that it is improving slightly

PMH - NIDDM, HTN

PSH - no surgeries

Allergies- NKDA

Meds - metformin 1000 mg bid, HCTZ 25 mg in AM, ASA 81 mg

FHx - mother w/diabetes, no bone or mineral metabolism history

SHx - office worker, one drink/week, no tobacco or drugs.

Objective

O: T 98.4 | BP 135/80 | P 75 | RR 18 | BMI 32

Gen - obese male in NAD

HEENT - PERLA, TM clear x 2, oropharynx clear no exudates

CV - RRR no m/r/g, 2+ pulses x 4, good cap refill

Pulm - CTAB no r/r/w, no dullness

Abd - + bowel sounds, soft nt/nd, aorta not appreciated

Back - no CVA tenderness, tender lumbar paraspinal muscles

Ext - no clubbing or cyanosis

Neuro - straight leg raise negative, Babinski downgoing.

Assessment and Plan

A/P: 53 y/o male with first occurrence lumbago, no alarm symptoms, likely MSK sprain.

Continue activity as tolerated

Stretching exercises

Ibuprofen 800 mg q4h as necessary for pain

Reassurance after three days.

Complete History

Mr. AA is a retired banker, aged 53 with no serious health problems for last 10 years. He performs regular activities without ...