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NUR 638SOAP-chronic lower back pain
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SOAP NOTE: CHRONIC LOWER BACK 1PAIN
Assignment 4.1: SOAP Note for Chronic Lower Back
Pain Treva Risher
Bradley University, Peoria, Illinois
This study source was downloaded by 100000832558064 from CourseHero.com on 04-11-2022 23:23:05 GMT -05:00
https://www.coursehero.com/file/55691400/SOAP-chronic-lower-back-paindocx/
, SOAP NOTE CHRONIC LOWER BACK 2
PAIN
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.
This study source was downloaded by 100000832558064 from CourseHero.com on 04-11-2022 23:23:05 GMT -05:00
https://www.coursehero.com/file/55691400/SOAP-chronic-lower-back-paindocx/
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