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Week 6 - Problem Focused SOAP

Detailed SOAP for low back pain with differential diagnoses

Course

Advanced Health Care Residency (NURS 668L)

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University

West Coast University

Academic year: 2022/2023

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Week 6: Problem-Focused SOAP Note

Banafsheh Mazloumi

West Coast University

NURS 668L-A Advanced Health Care Residency

Dr. Lisa Mathis

April 16, 2023

Demographics: B., 36-year-old female

Subjective

Chief Complaint: “This back pain is killing me” - patient

HPI G0P0 36-year-old Caucasian female presenting with lower back pain that she woke up with 5 days ago. Patient indicates the pain is localized to the center of the lower back, does not radiate, described as a sharp pain rated 7/10. Some relief with acetaminophen 1000mg being taken twice a day. Patient states that she continued to go to the gym but limited weight-lifting and was forced to stop workouts early due to pain. Patient states the pain has impacted her ability to complete daily tasks such as sitting at work for prolonged periods and tying her shoe-laces. Patient denies history of back pain. Denies history of falls. Denies history of fractures.

PMH:

LMP: 4/2/23, medium flow, lasts 4-5 days, regular 28-day cycle.

Surgeries: none

Hospitalization: none

Medical hx: history of childhood asthma.

Medications: oral Lipitor 40mg, Mirena IUD 2020

Allergies: NKA

Immunizations: COVID x3, all Pfizer, last in December 2022

Preventative Health History: Family History: mother (62) –depression, hyperlipidemia; father (65) – hyperlipidemia Maternal grandmother: hypothyroidism, stomach cancer (died at 91), maternal grandfather: medical history unknown, died from MI at age 89 Paternal grandmother: unknown Paternal grandfather: unknown

Social History: G0P0 female patient lives with her husband and works as a personal trainer. Patient has 0 siblings. Patient endorses social drinking of alcohol (3x per month or less), denies history of smoking cigarettes. Patient denies use of recreational/illicit drugs. Denies history of sexual, emotional, and physical abuse. Highest education – high school in Israel.

Constitutional/General: Denies fever, chills, night sweats.

Cardiovascular: denies chest pain, SOB, palpitations, diaphoresis, dizziness, syncope Respiratory: denies cough, sputum, SOB, wheezing, difficulty breathing Gastrointestinal: denies nausea, vomiting, alterations in elimination patters, denies incontinence, denies abdominal pain Musculoskeletal: endorses 5/10 sharp/aching pain in the middle lower back, denies radiation Genitourinary: denies incontinence Neurological: denies numbness, denies tingling, denies weakness

PLAN

POC testing: none Laboratory studies  None: consider imaging if pain persists past 12 weeks Orders  Naprosyn 250mg oral tablet – 1-2 tablets orally every 12 hours as needed for pain for 14 days, # o Administer with food, milk, or antacids to decrease GI adverse effects o Swallow tablet whole: do not break, crush, chew Referrals  None: consider PT referral Patient Education o Avoid activities that worsen your pain. o As your pain improves, stay active to recover faster: it’s important to get back to walking and moving as soon as possible. o Applying heat pads or ice packs can help with pain: be careful not to leave either on for longer than 15 minutes at a time. Prognosis: Good, patient is otherwise healthy and in good physical condition. Follow-up:  Follow-up in 2 weeks or sooner symptoms do not resolve or worsen.

National Standards of Care - Initial evaluation of low back pain aims to rule out serious etiologies such as cauda equina syndrome, metastatic cancer, and spinal infection through history and physical to identify red flag signs/symptoms: fever, weakness, unexplained weight-loss, nighttime pain, pain not relieved by changing positions, or incontinence (Casiano et al., 2023). Once these are ruled out, the patient can be educated about the self-limited nature of most cases of back pain with improvement over a few weeks. Imaging is often of little value at initial evaluation in the absence of red flag signs/symptoms (Casiano et al., 2023). Treatment with pain management, initially with NSAIDs, and patient education to remain active are associate with positive outcomes (Casiano et al., 2023).

References

Casiano, V., Sarwan, G., Dydyk, A., Varacallo, M. (2023). Back Pain. StatPearls.

Davis, D., Maini, K., Vasudevan, A. (2022). Sciatica. StatPearls.

Wheeler, S., Wipf, J., Staiger, T. (2023). Evaluation of low back pain in adults. UpToDate.

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