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Episodic/Focused SOAP Note Template
DW 45 Caucasian Male
HPI: David reports suffering from lower back pain. The pain started approximately one month ago. It is a burning shooting pain that radiates to his left leg. Sometime the pain is associated with numbness in the left foot and tingling in the left leg. He mostly notices the pain when he’s been standing for an extended period of time. Standing makes the pain worse but sitting seems to help. David has tried over the counter medications including Tylenol, Motrin, and Aleve but none of those seem to make a difference. He’s also recently found some stretching videos online that seem to help reduce the number of what he refers to as ‘flare ups’ each day. He rates the pain as a 7/10 when he experiences it but denies pain at this time.
Current Medications: None
PMHx: Childhood immunizations are up to date. Received the flu shot last week. Last Tetanus 2014. Soc Hx: David is a construction worker and cleans pools on the weekend. He is married with 2 adult children. David SCUBA dives and sky dives recreationally but hasn’t recently. He denies any use of alcohol or recreational drugs. David was a pack/day smoker for 12 years but quit 15 years ago. David never goes to the doctor but regularly monitors his blood pressure at his local pharmacy. He does not have health insurance.
Fam Hx: Father: deceased at 81- stroke. Mother: deceased at 83 Alzheimer’s disease. Brother: deceased at 32- suicide. Sister: 41- Breast CA at 30. 3 other sisters and 2 brothers living. No other pertinent family history.
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia. No change in bowel or bladder control. Numbness noted on occasion to left lower leg and foot and tingling the radiates up and down his left leg. Weakness when standing for long periods.
MUSCULOSKELETAL: Lower burning back pain that radiates to the left leg.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
VS: BP 128/76; P 77; R 22; T 97.8; 02 98% Wt 220lbs; Ht 70”
General–Pt appears in good health with a apple shaped abdomen. Appropriate. Alert, oriented.
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. S1,S2. No murmur. No edema. Good radial and DP pulses. Cap refill <3secs.
Pulmonary— Lungs are clear to auscultation and percussion bilaterally.
Neurological— Good strength in all ext against resistance. Able to lift legs bilaterally and hold. Pain in left buttock and lower back when lifting left leg off the bed. Differentiates between sharp and dull sensations throughout both lower extremities. No numbness or tingling at this time.
Musculoskeletal –Complains of pain in lower back and left buttock when lifting left leg off bed. Describes pain in lower back when walking on toes and heels. Complains of pain when asked to stand from a squatting position.
Diagnostic results:Diagnostic results: MRI shows herniated disk at L1-L2.
1) Herniated disk. This can cause nerve root irritation that may travel below the knee (Dains, 2019).
2) Sciatica. The most common cause is a herniated vertebral disk or spinal stenosis (Mayo Clinic, 2019)Low levels of physical activity and obesity increase a patient’s risk of radiating low back pain (Shiri, 2013). Occupations that require twisting and bending or carrying heavy loads can lead to sciatica pain(Mayo Clinic, 2019).
3) Musculoskeletal strain. With this type of injury, patients often report pain that is exacerbated by sitting or standing for long periods of time (Dains, 2019). Patients often describe relief from pain with rest, as seen in this case (Dains, 2019).
4) Spinal Stenosis. Spinal stenosis will result in pain while walking or standing for long periods of time that often gets better with rest or forward flexion of the spine (Dains, 2019). It is most often seen in patients over the age of 50 (Dains, 2019).
5) Tumor. This is unlikely, but possible. Patients with tumors usually present with weight loss, fatigue, weakness and anemia (Dains, 2019).
Primary Diagnosis/Presumptive Diagnosis: Herniated Disk and related sciatica pain.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Dains, J. E. (2019). Advanced health assessment and clinical diagnosis in primary care(Vol. 6). St.Louis, Missouri: Elsevier Mosby.
Mayo Clinic. (2019, September 26). Sciatica. Retrieved from Mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/sciatica/diagnosis-treatment/drc-20377441
Shiri, R. S.-P.-J. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640-650.
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