CC: "I've been having lower back pain for the past week."
HPI: The patient is a 46-year-old white female who presents with a one-week history of lower back pain. The pain is
described as a dull, constant ache, rated 5/10 in severity, and occasionally radiates to the left buttock. The pain is
agg...
CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 08/08/24 Time: 1315
J.T.
Ethnicity: White Age: 46 Sex: F
SUBJECTIVE (must complete this section)
CC: "I've been having lower back pain for the past week."
HPI: The patient is a 46-year-old white female who presents with a one-week history of lower back pain. The pain is
described as a dull, constant ache, rated 5/10 in severity, and occasionally radiates to the left buttock. The pain is
aggravated by prolonged sitting, standing, and lifting heavy objects, and is partially relieved by rest and over-the-
counter ibuprofen. The patient denies any recent trauma or injury but notes that she has been working longer hours
at a desk job. She reports occasional stiffness in the morning, which improves with movement. There are no
associated symptoms of numbness, tingling, or weakness in the lower extremities. No changes in bowel or bladder
function have been noted.
Medications:
Previous Medical History: HTN, Hypothyroidism
Medications: Lisinopril 10mg daily, levothyroxine 75mcg
daily Allergies: NKA
Medication Intolerances: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- htn, diabetes 2, hyperlipidemia, osteoarthritis
F: MI at 70, deceased
Social History: The patient is a non-smoker, consumes alcohol occasionally, and does not use illicit drugs. She works as an
office manager and leads a sedentary lifestyle with limited physical activity.
REVIEW OF SYSTEMS (must complete this
section)
General: Denies fatigue, night sweats and Cardiovascular: Denies syncope, edema,
weakness shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Reports productive cough,
denies difficulty breathing, shortness of
breath, labored breathing, tachypnea,
wheezing, retractions, and
stridor
Eyes: Denies and visual changes, eye Gastrointestinal: Denies abdominal pain,
drainage or eye pain spitting up/vomiting, diarrhea, and changes in
stool.
Ears: Denies ear pain and swelling Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Denies nasal Musculoskeletal: Reports lower back pain,
congestions no
or sore throat joint swelling or erythema
Breast: Deferred Neurological: Denies numbness. Tingling
, or
weakness in the legs
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