Episodic/Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Episodic/Focused SOAP Note
Patient Information:
A, 42, M
S (subjective)
CC (chief complaint): Pain in the lower back for the past month. The pain sometimes radiates to his left leg.
HPI (history of present illness): A is a 42-year old male of unknown ethnicity who comes to the clinic complaining of lower back pain for the past month. The pain sometimes radiates to the left leg. The pain has affected the patient’s ability to perform daily duties due to immobility. The pain exacerbates when moving. He rates the severity of the current back pain at 6 out of 10. The patient has taken ibuprofen 400mg twice daily for the past two weeks with minimal relief.
Current Medications:
Ibuprofen 400mg BID PRN for back pain
Lisinopril 10mg PO QD
Allergies:
No known drug allergies
PMHx:
HTN
Soc and Substance Hx:
Non-smoker, no alcohol use, or illicit drug use. He works in a local factory as a supervisor. He has a wife and two daughters. He loves hiking.
Fam Hx:
Mother deceased Hx HTN, DM
Father alive with no significant medical history.
Siblings have no significant medical history.
Surgical Hx:
None
Mental Hx:
Depression and anxiety
Violence Hx:
None
Reproductive Hx:
Married, sexually active with his wife. Two daughters who are in high school.
ROS (review of symptoms):
• GENERAL: Denies fever, chills, night sweats, or recent weight changes.
• HEAD: No pain or swelling.
• EENT (eyes, ears, nose, and throat): No swelling or discharge, no blurred or double vision, no running nose, and no sore throat.
• RESPIRATORY: No coughing.
• CV: Denies
• GI: Denies N/V/D
• GU: No changes in urinary patterns.
• NEURO: NO dizziness or headache. No changes in body movement and memory patterns. No history of seizure or problems with coordination.
• LYMPH/HEME: Denies
• ENDOCRINE: Denies
• MUSCULOSKELETAL: Back pain reported.
• HEMATOLOGIC: No bleeding or anemia.
• LYMPHATICS: No history of splenectomy.
• PSYCHIATRIC: No history of depression.
• ENDOCRINOLOGIC: No reports of sweating or heat intolerance.
• REPRODUCTIVE: Sexually active.
• Allergic/immunologic: No history of rhinitis or asthma.
O (OBJECTIVE)
Physical exam:
Vital signs: Temperature: 98.6, Pulse 78, RR 18, BP 112/72, Weight 172lb Height 5’10
Diagnostic results:
X-ray lumber spine
CT cervical spine/lumber spine
A (assessment)
Differential diagnoses:
M54.3 Sciatica
Sciatica is the main diagnosis since it causes back pain that radiates to the legs. The condition affects one side of the body. The condition leads to severe pain, numbness, or weakness in the lower back, pain that worsens with movement, pin, and needles feelings in the legs (Parreira et al., 2018). The burning sensation causes difficulty in movement. The patient is likely suffering from the condition due to the common symptoms evident in the patient (Parreira et al., 2018). The risk factors of the condition include age and obesity.
M51. 26M51.26 Herniated lumbar spine
The herniated lumbar spine is a condition that affects the rubbery discs in the spinal bones. Some people can experience the condition without any pain (Cunha et al., 2018). In some patients, the problem can affect neighboring nerves causing pain in the arm or leg. Herniated discs are in the process of degeneration (Cunha et al., 2018).
S39.012A Muscle strain
A muscle strain occurs when the muscles are stretched and torn. The condition can occur due to wrong use, overstretching the muscles, and fatigue (Green & Pizzari, 2017). The effect on the muscles is common on the back, arm, neck, and hamstring. The symptoms of muscle strain include lack of strength or ability to move, sudden pain, bruising, and swelling (Green & Pizzari, 2017).
M48.06 Spinal stenosis, lumbar region
Spinal stenosis is a condition that leads to the narrowing of spaces in the spine. The condition mostly occurs near the neck or lower back. One of the major symptoms is lower back pain or pain around the neck (Jensen et al., 2020). Some patients may have no symptoms until the condition worsens. In other cases, patients may experience tingling and weakness in the arm or leg (Jensen et al., 2020).
M45.9 Ankylosing spondylitis
Ankylosing spondylitis is an inflammatory disease that causes the spine to fuse. The fusing makes the spine less flexible. It causes pain and difficulty in bending (Watad et al., 2018). The condition can lead to a hunched position or difficulty in breathing. Ankylosing spondylitis leads to a dull pain that emanates from the lower back or buttocks (Watad et al., 2018).
P (plan)
Treatment of sciatica will depend on the severity. Despite the level of pain, a combination of pharmacological and physical therapy interventions is critical. The first intervention is painkillers to alleviate the pain. The patient should continue taking ibuprofen (Jensen et al., 2019) 400mg BID or a higher dose if the pain persists. The patient should take muscle relaxants to ease muscle movement. Lioresal baclofen 10 mg BID is vital to enhance muscle relaxation (Jensen et al., 2019). If the pain persists, an MRI will be critical in providing a detailed image of the lower back.
Eating a healthy meal is critical for the patient to improve the general fitness of the body. Eating healthy meals is a strategy for maintaining body fitness. It improves body health and prevents conditions such as obesity (Boote et al., 2017). Obesity is a major factor that can complicate the body’s health and cause stress on the nerves. The patient should maintain a good posture and sit appropriately while working. Good posture is critical for the health of a patient with back pain or spine problems (Boote et al., 2017).
A referral to a specialist in physical therapy will be critical for the recovery of the patient. Physical therapy is critical to ease the pain. Although sciatica causes pain and inactivity, patients shouldn’t stay in bed (Boote et al., 2017). Working with a physical therapist or physiatrist can increase the chances of recovery.
If the two interventions are not working, alternative medication such as acupuncture or surgery can alleviate the pain (Shiri et al., 2017). A therapist has a responsibility to review the progress of a patient before opting for alternative medication.
It is vital to educate the patient on lifestyle such as avoiding sitting on low surfaces, bending, or lifting heavy objects. A patient should stay active since staying in bed can worsen the situation. Educating the patient on adherence to the medication is crucial for recovery (Shiri et al., 2017). The patient should adhere to the medication and report after two weeks.
The patient should come for follow-up care after a week and two weeks consecutively. The follow-up care may take even a month depending on the improvement. Coordination of care among the different specialists is critical for recovery. Appropriate interventions should be taken depending on the outcome and the process of recovery.
Reflection
The case study of the patient is an eye-opener since it provides new insights into the different diagnostic tools and differential diagnoses. I learned that accuracy in the provision of care for patients in pain is vital for recovery. For instance, pain management can improve the movement of a patient. I learned that patients start treating conditions involving pain by taking over-the-counter drugs. An examination of the drugs a patient is taking is critical in the determination of the drugs a patient should start taking.
An evaluation of the patient’s lifestyle is critical for the recovery and prevention of similar conditions in the future. For instance, the patient should avoid heavy tasks that involve stretching the back or muscles. The patient should stay active since bed rest is not the best intervention for patients with sciatica. It is vital to educate the patient to avoid lifting heavy objects or carrying out strenuous activities. For instance, going for a walk is a strategy of being active. It helps a person to avoid the risk of sitting for long hours, which can complicate back pain.
During the provision of care, adherence to ethical considerations in nursing is critical in the delivery of patient-centered care. Patients of unknown ethnicity should receive quality care without any form of discrimination. Justice in nursing involves the observation of fairness in the delivery of care (McDermott-Levy et al., 2018). Veracity involves telling the truth to the patient. For instance, telling the patient about the causes of sciatica and other conditions that lead to back pain will help adjust lifestyles (McDermott-Levy et al., 2018). A nurse practitioner should utilize the best knowledge available in treating the patient. nonmaleficence involves the provision of care while taking utmost care to avoid harm (McDermott-Levy et al.,2018). Ethical practice is safe for patients and improves the level of confidence in patient outcomes.
References
Boote, J., Newsome, R., Reddington, M., Cole, A., & Dimairo, M. (2017). Physiotherapy for patients with sciatica awaiting lumbar micro‐discectomy surgery: A nested, qualitative study of patients’ views and experiences. Physiotherapy Research International, 22(3), e1665.
Cunha, C., Silva, A. J., Pereira, P., Vaz, R., Gonçalves, R. M., & Barbosa, M. A. (2018). The inflammatory response in the regression of lumbar disc herniation. Arthritis research & therapy, 20(1), 1-9.
Green, B., & Pizzari, T. (2017). Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British journal of sports medicine, 51(16), 1189-1194.
Jensen, R. K., Jensen, T. S., Koes, B., & Hartvigsen, J. (2020). Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. European Spine Journal, 1-21.
Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. bmj, 367.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing outlook, 66(5), 473-481.
Parreira, P., Maher, C. G., Steffens, D., Hancock, M. J., & Ferreira, M. L. (2018). Risk factors for low back pain and sciatica: an umbrella review. The Spine Journal, 18(9), 1715-1721.
Shiri, R., Euro, U., Heliövaara, M., Hirvensalo, M., Husgafvel-Pursiainen, K., Karppinen, J., … & Lallukka, T. (2017). Lifestyle risk factors increase the risk of hospitalization for sciatica: findings of four prospective cohort studies. The American journal of medicine, 130(12), 1408-1414.
Watad, A., Bridgewood, C., Russell, T., Marzo-Ortega, H., Cuthbert, R., & McGonagle, D. (2018). The early phases of ankylosing spondylitis: emerging insights from clinical and basic science. Frontiers in immunology, 9, 2668.
