SOAP NOTE
Title: M.A Date: 04/11/2021 Time: 10:45 am
Age: 55 Intercourse: M
SUBJECTIVE
CC: “Again ache after a fall from a ladder”
HPI:
Affected person is a 55-year-old African American male, typically wholesome, no change in energy or train tolerance. That current to the workplace for analysis as a result of 5 days in the past he fell from a ladder 5 toes on the grass, obtained contusion on the again, denied lack of consciousness, paresthesia, dizziness, or vomiting. Now he is complaining about again ache 10/10.
Drugs: Denies
PMH
Allergic reactions: Denies any allergic reactions to meals or remedy
Medicine Intolerances: Denies.
Persistent Sicknesses/Main traumas Regular childhood sickness
Hospitalizations/Surgical procedures: Denies
Household Historical past
Mom: Deceased, coronary heart assault
Father: alive, CAD, CHF.
Brothers: 1 Alive wholesome.
Sister: 1 Alive wholesome.
Social Historical past
Affected person is a truck driver, Married, sexually lively Heterosexual, drinks alcohol sometimes. Affected person denies any medication consumption.
ROS
Common
Common Affected person seems to be in good well being no misery famous at this second, responding query in an appropriated temper; affected person denied any change in weight or vitality ranges. No change in energy or train tolerance.
Cardiovascular
Affected person denies chest ache and palpitation. No edema seen no syncope, no orthopnea.
Pores and skin
Heat and dry, No rashes bruising or bleeding seen, pores and skin is appropriated shade for ethnicity.
Respiratory
Affected person with out dyspnea, no wheezing, no hemoptysis, no cough or any acute misery at this second.
Eyes
Regular imaginative and prescient, denies blurred imaginative and prescient, diplopia, no imaginative and prescient loss, or ache. Gastrointestinal
No change in urge for food, no dysphagia denies heartburn or belly discomfort, denies nausea vomiting and diarrhea presently.
Ears
No change in listening to, no tinnitus, no bleeding, no vertigo. Genitourinary/Gynecological
Male affected person denies bleeding, discharge or urinary signs (urgency, frequency burning, change in shade of urine).
Nostril/Mouth/Throat
Affected person denies nasal congestion, sore throat or troublesome to swallow. Musculoskeletal
Thoracic and Decrease again Ache after fall (10/10) Ache Scale, no ache in joints, no limitation of vary of movement, no paresthesia or numbness.
Breast
N/A Neurological
No weak point, no tremor, no seizures, no change in mentation, no ataxia, and denies dizziness
Heme/Lymph/Endo
No bruises, hematomas, ecchymosis, lymph nodes or mass. Psychiatric
Denies melancholy, signs, no change in sleep habits, any suicidal ideation or temper change.
OBJECTIVE
Weight 180.00 lbs BMI 23.1 Temp 98.5 F BP 130/85
Peak 6.2 in Pulse 86 bpm Resp 18 bpm
Common Look
Affected person in ache, in no acute misery. Regular vitality stage.
Pores and skin No pallor, jaundice, ecchymosis, or rash. Good pores and skin turgor.
HEENT
Head is atraumatic and normocephalic. Eyes: PERRLA, EOM’s Full. No lesions on exterior ear, TM’S regular. Hair is evenly distributed. Lymph nodes should not palpable. Neck is supple and trachea in midline. Good dentition. Thyroid gland inside regular limits for dimension and consistency. No cervical lymphadenopathy or mass.
Cardiovascular
Common rhythm and charge.
No murmur, no rubs or gallop upon auscultation.
No peripheral edema
Respiratory
Lungs clear bilaterally upon auscultation, no rales, no rhonchi, and no wheezes.
Breath sounds equal, no rubs
Gastrointestinal
Stomach no distends.
No hepatosplenomegaly, mass, or herniation
Stomach Tender, non-tender all through , BS regular in all four quadrants
Breast
Breast is free from lots or tenderness.
Genitourinary
Regular exterior genitalia, no palpable lots within the suprapubic space.
Musculoskeletal
Regular gait, no limping or musculoskeletal deformities. Again: regular exterior curvature, constructive tenderness, Thoracic and lumbar backbone, paravertebral muscle spasm. Extremities: ROM: wnl, no deformities.
Neurological
Reflexes 2+ bilaterally all through
CN II-XII intact
Psychiatric
Common sense, awake, alert and oriented answering questions.
Lab /Checks/Screening/Intervention/Evaluation:
Backbone Thoracic and Lumbar X-ray 2 views.
Grownup melancholy Screening evaluation.
Documentation of present remedy.
Ache care documented
Particular Checks
Not carried out
Prognosis
M54.9 | Dorsalgia, unspecified
M54.5 | Low again ache
Plan/Therapeutics
Plan:
Mentioned compliance with remedy.
Sickness counselling.
Examine blood strain three instances per week, for two weeks, report and herald log.
Sing launch consent kind.
RCT or name if no enchancment.
RTC in 2 weeks.
Drugs:
1.- Cyclobenzaprine HCL10 mg tab: Take 1 tab (10mg) P/O 2 instances per day as wanted #30 NR.
2.- Ketorolac tromethamine 60 mg/2ml ing sol. Administer 2 ml (60mg) IM Stat.
three.- Tramadol HCL 50 mg oral pill: take 1 pill by mouth each 6 hours as wanted #50 NR.
Therapy for again ache typically relies on whether or not the ache is acute or continual. Conventionally used remedies and their stage of supportive proof embody:
Scorching or chilly packs have by no means been confirmed to rapidly resolve low again damage; nevertheless, they might assist ease ache and cut back irritation for folks with acute, subacute, or continual ache, permitting for larger mobility amongst some people.
Exercise: Mattress relaxation must be restricted. People ought to start stretching workout routines and resume regular day by day actions as quickly as potential, whereas avoiding actions that worsen ache. Robust proof reveals that individuals who proceed their actions with out mattress relaxation following onset of low again ache appeared to have higher again flexibility than those that rested in mattress for per week. Different research recommend that mattress relaxation alone could make again ache worse and might result in secondary problems similar to melancholy, decreased muscle tone, and blood clots within the legs.
Strengthening workout routines, past common day by day actions, should not suggested for acute low again ache, however could also be an efficient technique to pace restoration from continual or subacute low again ache. Sustaining and constructing muscle energy is especially necessary for individuals with skeletal irregularities. Proof helps short- and long-term advantages of yoga to ease continual low again ache.
Bodily remedy packages to strengthen core muscle teams that help the low again, enhance mobility and adaptability, and promote correct positioning and posture are sometimes utilized in mixtures with different interventions.
Drugs: A variety of medicines are used to deal with acute and continual low again ache. Some can be found over-the-counter (OTC). The next are the primary kinds of medicines used for low again ache: Analgesic medicines are these particularly designed to alleviate ache. They embody OTC acetaminophen and aspirin, in addition to prescription opioids similar to codeine, oxycodone, hydrocodone, and morphine. Nonsteroidal anti-inflammatory medication (NSAIDS) relieve ache and irritation and embody OTC formulations (ibuprofen, ketoprofen, and naproxen sodium). Anticonvulsants: could also be helpful in treating folks with radiculopathy and radicular ache.
Reference:
Bethesda, M. 2. (December 2014). Low Again Ache Reality Sheet. Nationwide Institute of Neurological Issues and Stroke.
Analysis of affected person encounter
Interview course of went nicely, practitioner elaborated the plan of care with affected person, and training was supplied and verbalized understanding.
