NURS 634SOAP NOTE MSK-Low Back Pain latest

NURS 634SOAP NOTE MSK-Low Back Pain latest SOAP # 4: MSK-Acute Low Back Pain Shumeka Hill, APN, PNP-AC UMASS History & Physical Examination Patient Demographics: Name: T.H. Age/race/sex: 26 Hispanic Female Clinical site: Primary Care clinic; Presents for sick visit. SUBJECTIVE DATA Chief Complaints: “My lower back has been hurting for about 2 weeks now”. History of Present Illness: Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline, who presents to the clinic today complaining of spontaneous occurring acute low back pain to lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has been very difficult to dress lower body and to bend. She reports the pain is constant but has intermittent intensities of aching and soreness throughout the day. The pain is localized to the lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has experienced. Reports the pain is worse in the mornings when getting out of bed after lying down all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped head first over the handle bars of the bike. At which time she experienced this same low back pain, went to the ER and had X-rays that showed some inflammation and swelling. She was then prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped tremendously. At today’s visit, she hopes to find out where the pain is coming from and what she can do to prevent it from returning. Past Medical History: •Depression-active- diagnosed 6 years ago after mom passed in a MVA •Low back pain-active-diagnosed about 5 years ago after previous back injury. Past Surgical History: •No surgeries to date Allergies: NKA to food, dust, mold, environment, or medications. Medications: Sertraline 150 mg by mouth daily for depression Health Maintenance: •Influenza Vaccine-October 2017 at CVS. •All other immunizations are up-to-date including TDaP, MMR, and Varicella. •Last Pap smear- June 2016-normal •Performs MSBE •Depression screen positive for PHQ2; on meds and see Psychologists regularly. •CAGE 0/4 Personal & Social History: •Lives alone in a one bedroom apartment. •Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her job and has a dependable car. •Denies any smoking, illicit drug abuse, or alcohol misuse. •Previously did cross fit in high school. However, do to work she hasn’t had much time to get the amount of exercise she needs. •Patient is sexually active with only one sex partner, her boyfriend. •24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a diet coke; S-about 1-2 cups of cheese-it crackers and a diet coke; D- Meatloaf, veggies, mashed potatoes from Boston Market, and a bottled water. Family History: Grandparents Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76 history of DM and MI. Maternal: Maternal grandfather died at 82 from MI, maternal grandmother 79, history of diabetes and arthritis. Parents Father: Father 59, history of HTN, Diabetes, Depression, and Stroke. Mother: Mother 52, died in a MVA. Siblings Siblings: Only child. Children Children: No children. Review of Systems: Skin Denies dry skin and itching. Denies abnormal lesions or new nevi/moles Head Previous head injury, denies any masses, lesions and headache Eyes Denies any discharge, itchy, blurred vision, vision loss or vision changes, eye pain or injection. Ears Denies any itching, fullness, vertigo, ear pain or drainage, hearing loss or changes in quality of hearing. Nose/Sinuses Denies epistaxis, PND, maxillary or frontal sinus pain, or changes in smell Mouth/Throat Denies sore throat and dysphagia. Denies gum disease, has all original teeth, last dental exam was in July of this year, sees the dentist annually. Neck/Lymph Nodes Denies swollen /painful lymph nodes, denies any neck pain or stiffness. Breasts Denies masses, pain, or nipple discharge. Does perform regular SBE. Thorax/Respirator y Denies any SOB, DOE, or wheezing. CVS Denies CP, palpitations, denies peripheral edema, Orthopnea GI/Abdomen Denies dyspepsia, nausea, vomiting, diarrhea, constipation, bloating, hematemesis, hematochezia, or abdominal pain. No recent changes in bowel habits. Last bowel movement was this morning, which is consistent with her regular bowel habits and was normal. GU Denies any pain on urination, frequency, urgency, or vaginal discharge. Musculoskeletal See HPI. Neurologic Denies memory loss, numbness, tingling, or burning pains or weakness. Endocrine Denies known glucose abnormalities, heat or cold intolerance Psychiatric Reports a history of depression but denies any anxiety. Physical Examination: OBJECTIVE Vital Signs/HT/WT T: 98.2F, P: 72 readily palpable, RR: 16, BP 110/64 on right, 110/68 on the left SaO2 on RA: 100% HT: 5’8”, WT: 128lbs (toned-physique, stable with no gains or losses within the last 6 months), BMI: 19.46, normal for ht. and wt. General 26 y/o Hispanic female, pleasant appears her stated age sitting on the examination table in moderate distress as evidenced by arms tensed on elbows as she’s guarding pain. Well groomed, well developed, AAOx3 Skin Warm, moist, no rashes or suspicious moles, +turgor