NURS6512 Discussion- Week 8 Episodic/focus SOAP Note Template

NURS6512 Discussion- Week 8

Episodic/focus SOAP Note Template

Case 1: Back Pain

Patient Information

Initials: H.H Age: 42 Gender: Male. Race: Caucasian

SUBJECTIVE DATA:

Chief Complaint (CC): “Lower Back Pain”

History of Present Illness (HPI): Patient is a 42-year-old white male who developed lower back pain that has been bothering him for the past month. He states that the pain radiates to his left leg sometimes, and it increases with sitting for a long period of time but gets better when standing. Severity of pain is 7/10 on pain scale of 0/10.

Current Medications: OTC Ibuprofen 300mg 2 tablets every 6hours PRN for Lower back pain.

Amlodipine 10mg 1 tab PO daily for hypertension

Allergic/Immunologic: No known drug, food seasonal, latex/rubber allergies

Past Medical History (PMH): Lower Back Pain

Past Surgical History (PSH): None

Sexual/Reproductive History: Single with no kids.

Personal/Social History: Patient works at a storage company as an assistant manager. He enjoys hiking, surfing, and skiing. He reports drinking alcohol on rare occasions, denies illicit drug use and smoking tobacco. He reports a healthy lifestyle including lifting weights three times a week and eating a high protein and low carb diet.

Immunization History: Influenza 11/1/2020, Pneumovax 05/2020. Tetanus-Unknown

Significant Family History:

Father: Father is 79 and still living. He has Hypertension, diabetes type 2, and asthma.

Paternal Grandmother: She had hypertension and died at the age of 85.

Paternal Grandfather: Died at the age of 80, had asthma.

Mother: His mother is still alive and has diabetes type 2.

Maternal Grandfather: Died at the age of 80, had type 2 diabetes.

Maternal Grandmother: Died at the age of 85, had a stroke.

Sister: Age 45, has type 2 diabetes.

Review of Systems:

General: The patient is alert and oriented to person, place, time and situation, appropriately dress according to the weather, good judgement, and a well-nourished Caucasian male. No distress noted but mild discomfort due to pain in his lower back radiating to his left leg. His emotional and behavioral needs are appropriate at the present time considering patient’s clinical condition. Denies current home stress and abuse.

HEENT:

· Eyes: Patient denies itching eyes or discharges, uses glasses but does not use contact lens, and denies blurred vision.

· Ears: He denies ringing in the ears, hearing loss, and discharged. He also denies surgery to the ears and any recent infections.

· Nose: Denies epistaxis, discharges, congestion, and sneezing. Denies loss of smell.

· Throat: Denies any sore throat, or infection. Denies difficulty swallowing.

· Skin: Negative for skin lesion, mole eczema or rash and no skin changes.

· Neck: No

· Respiratory: Denies shortness of breath, or difficulty breathing, coughing, wheezing, and secondhand smoking.

· Cardiovascular/Peripheral Vascular: Denies chest pain, heaviness, or heart palpitation, and edema to bilateral lower extremities.

· Gastrointestinal: Denies any abdominal upset, nausea or vomiting, have regular bowel movements. Denies change in appetite, and recent weight loss.

· Genitourinary: Denies difficulty voiding, changes in voiding pattern, and any penile discharge.

· Musculoskeletal: Complaints of Lower back pain that radiates down to the left leg. Denies any joint stiffness or joint pain.

· Psychiatric: Mr. H.H states that he is fine., denies any mental problems or issues, denies having depression, suicidal thoughts. He states that he loves his wife and family and can never commit suicide.

· Neurological: denies light headedness, fainting, seizure, vision changes or weakness to any side of his body. Also denies changes in his thinking. Denies syncope, seizures, or tremors. States, pain and burning sensation in left buttocks down left leg past knee.

· Hematologic: Denies any bleeding. Denies history of blood transfusions, clotting disorders, or easy bruising.

· Endocrine: Denies cold or heat intolerance, excessive thirst, or urination, does not have any issues with thyroid. Denies unexplained weight gain or loss, skin dryness or cracking.

OBJECTIVE DATA:

Physical Exam:

Vital signs: B/P 148/88; P 75; R 18; T 98.0F orally; 02 SAT 97% on room air; Wt: 155lbs; Ht: 5’11”; BMI: 20.2 Pain 7/10 on a scale of 0-10 at rest.

General: Patient is a 42-year-old male who presents as a well-developed young adult at his age. He is alert, oriented, and cooperative. The patient walks with slight limp.

HEENT:

· Head: Normocephalic head with normal distribution of hair. No facial tenderness to light sensation.

· Eyes: Conjunctivas are pink with white sclera and without jaundice. PERLA, with pupils 3mm in size bilaterally. No exudates seen. Corneal light reflex intact. No nystagmus noted. Red reflex present. Optic disc creamy pink with sharp, well defined margins. Retina- pink without vascularization.

· Ears: Auricles symmetrical bilaterally without pain or tenderness. Use of otoscope visualized external auditory canal, and middle ear showing mild redness and bulging, with serum fluid. Tympanic membranes are pearly grey with bony landmarks and light reflex visualized bilaterally. No drainage from ear, and no facial grimace noted upon examination. Patient is not pulling or tugging on ear or showing signs of distress.

· Nose: Nasopharynx and pharynx without erythema, lesion, or exudates. Mucous membranes are moist.

· Throat: Uvula midline, palate rises symmetrically. Oropharynx clear. No sore throat, with swallowing, or enlarge nodes, no redness. Tongue beefy and symmetrical without crusting. Upper, and lower teeth in good condition and intact.

· Skin: Dry and warm to touch. Not pale, cyanosis or ashen. No tear and non-tainting.

· Neck: Normal ROM, Supple with no JVD or bruits. JVD 6cm at 45-degree elevation. Thyroid moves freely with swallow test. No nodules or masses or lesions. No lymphadenopathy. Trachea midline. There is no adenopathy.

· Chest/Lungs: Clear to auscultation bilaterally anteriorly and posteriorly with equal symmetry of chest rise and fall. Breathing appears non-labored. Respiratory excursion 4cm bilaterally. Appears quiet and at ease. No adventitious sounds. Tactile fremitus symmetrical. Resonance noted to percussion bilaterally. No wheezes, rhonchi or stridor. No complaint of SOB, no cough. No pain or tenderness noted over ribs or bony prominence. No pain noted when palpating breasts. No swollen axillary lymph nodes.

· Heart/Peripheral Vascular: The heart rate is regular with a normal rhythm. PMI is heard at the fifth intercoastal space midclavicular line. S1, and S2 normal. All peripheral pulses are strong and palpable 3+, Negative edema to all extremities. Capillary refill is less than/equal to 2seconds in all extremities and no cyanosis noted or clubbing on nails.

· Abdomen: Soft and nondistended, bowel sound present and active in all four quadrants, no pain or rebound tenderness noted. Last bowel movement was this morning. The liver span percussed to 9cm. No hernias palpated. No hepatomegaly or splenomegaly noted. No renal artery bruits auscultated. Negative McBurney’s point.

· Musculoskeletal: Spine is vertically aligned. Normal S- curvature. No nodules, masses, or tenderness with palpation. Low back pain radiating to left lower extremity. No evidence of trauma to affected area. Full ROM in all joints. BUE and BLE symmetrical. No pain or tenderness with palpation of joints. Extremities symmetrical without atrophy or hypertrophy. No pain or tenderness with passive ROM. Active and Passive ROM equal between contralateral joints. No crepitation’s or tenderness with movement noted.

· Neurological: Patient is alert and oriented to place, person, time and situation, appropriate judgement. Speech is clear, no facial drooping, no vision changes, follows movement. Understand clear, complex, comprehensive without cues or repetition.

· Genital/Rectal: Penis and testicles without lesions. No inguinal hernias are present. Rectal exam had intact tone. Firm, symmetric, nontender prostate without nodules.

Diagnostic Tests:

· Walk across the room to examine abnormalities in gait (pattern of walking).

· Hip flexion and knee hyperextension up to 30 degrees. Bend or flex part of the spine to assess spinal range of motion.

· Complete Blood Count (CBC) may point to infections or inflammation.

· Erythrocyte sedimentation rate

· HLA-B27

· Bone scans

· X-ray of the lumbar spine

· Computerized tomography (CT) cervical spine/lumbar with without contrast to detect abnormal tissue, and the state of the patient’s spine.

· MRI of the lumbar spine to reveal the structure of soft tissues such as discs, spinal cord, and nerves.

ASSESSMENT:

Differential diagnoses:

Lumbar Disc Herniation (LDH): The intervertebral disc is made up of two parts: an inner nucleus pulposus (NP) and an outer annulus fibrosus (AF) (AF) (Wang et al., 202). The central NP is a site of collagen secretion and contains numerous proteoglycans (PG), which aid in water retention and create hydrostatic pressure to resist axial spine compression. The NP is primarily made up of type 11 collagen, which accounts for 20% of its total dry weight (Wang et al., 2019). The AF, on the other hand, uses a low amount of PG to keep the NP in the center of the disc; 70% of its dry weight is made up of primarily concentric type 1 collagen fibers. In LDH, narrowing of the space available for the thecal sac can occur as a result of disc protrusion through an AF, NP extrusion through the AF while still maintaining continuity with the disc space, or complete loss of continuity with the disc space and sequestration of a free fragment (Wang et al., 2019). This condition is thought to be inherited in approximately 75% of cases; other risk factors include dehydration and Axial Overloading. The role of inflammatory signaling in the production of nerve pain LDH is well known. Radicular pain, sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots are the primary signs and symptoms of LDH. This condition is detected using CT myelography and MRI (Amin, Andrade, & Neuman, (2017).

Lumbar Spinal Stenosis: The term “Lumbar Spinal Stenosis” refers to a narrowing of the spinal canal in the lower back (Fishchenko et al., 2018). Stenosis, or narrowing, can put pressure on the spinal cord or the nerves that connect the spinal cord to the muscles. In older people, lumbar spinal stenosis (LSS) is most commonly caused by degenerative changes. This condition is typically classified as either primary (caused by congenital abnormalities or a disorder of postnatal development) or secondary (acquired stenosis) when caused by degenerative changes or as a result of local infection, trauma, or surgery (Fishchenko et al., 2018). Anatomically, degenerative LSS can involve the central canal, lateral recess, foramina, or any combination of these locations (Fishchenko et al., 2018). A decrease in the anterior, posterior, transversal, or combined diameter of the central canal can occur as a result of disc height loss, bulging of the intervertebral disc, and hypertrophy of the facet joints and ligamentum flavum Fishchenko et al., 2018). Fibrosis is the most common cause of ligament flavum hypertrophy and is caused by accumulated mechanical stress, particularly along the dorsal aspect of the ligament flavum. The most common symptom associated with LSS is neurogenic claudication, also known as pseudo claudication. Neurogenic claudication refers to leg symptoms that affect the buttocks, groin, and anterior thigh, as well as radiating down the leg to the feet (Wang et al., 2019). Leg symptoms can include fatigue, heaviness, weakness, and/or paresthesia, in addition to pain. The symptoms can be unilateral or bilateral and symmetrical, which is more common. The patient may experience accompanying back pain, but leg pain and discomfort are usually more bothersome (Wang et al., 2019).

Lumbar Strain/Sprain: The lumbar spine relies on soft tissues to keep the body upright and to support weight from the upper body. When the lower back muscles or soft tissues are overstressed, they can become injured and painful. Lumbar sprain happens when ligaments become overstretched or torn. Ligaments are fibrous, tough tissues that connect bones. Sudden lower back pain is the most common symptom of a lumbar strain. Lower back spasms cause more severe pain, and the lower back feels sore to the touch. Diagnostic procedures for low back pain may include an X-ray, CT scan, and MRI, in addition to a thorough medical history and physical exam (AANS, 2020).

Sciatica: Low back pain is one of the most common conditions seen in clinical practice. Low back pain has significant direct and indirect costs, and it is a common cause of missed work. Sciatica, also known as radiculopathy, is caused by something pressing on the sciatic nerve, which runs through the buttocks and down the back of the leg. Sciatica patients may experience shock-like or burning low back pain, as well as pain through the buttocks and down one leg (AHRQ, 2016).

Spondylolisthesis: It is a spinal condition that affects the spinal bones. This disease causes one of the lower vertebrae to slip forward onto the bone directly beneath it (Genev et al., 2017). It’s a painful condition but treatable in most cases. The symptoms of spondylolisthesis vary. People with mild cases may not have any symptoms. However, those with severe cases may be unable to perform daily activities. Some of the most common symptoms are persistent lower back pain, stiffness in the back and legs, lower back tenderness, thigh pain, and tight hamstring and buttock muscles (Genev et al., 2017). Physical exams are the first step in diagnosing this condition. X-rays of the lower spine are crucial for determining whether a vertebra is out of place. A CT scan may also be ordered if the misplaced bone is pressing on the nerves. The treatment for spondylolisthesis depends on the severity of pain and vertebra slippage. Common nonsurgical treatment methods include wearing a back brace, doing physical therapy exercises, taking anti-inflammatory drugs, or using epidural steroid injections. Surgery may be required if other treatments fail.

Assessing Musculoskeletal Pain

Musculoskeletal pain primarily affects a person’s quality of life through factors such as sleep deprivation, fatigue, depression, and activity restrictions. The set effects are also influenced by contextual factors such as comorbidity, arthritis coping efficiency, and access to care (AANS, 2020). This implies that musculoskeletal (MSK) pain evaluation requires a set of bio-psychosocial perspectives that include pain, baseline effects, and contextual factors.

Back pain nerve roots exhibit a multifaceted, heterogeneous state in which both nociceptive and neuropathic pain mechanisms may be involved. The pain is caused by the activation of nociceptors that innervate ligaments, joints, muscles, fascia, and tendons. This is due to the body’s reaction to tissue injury or even inflammation, in combination with biomechanical stress. The neuropathic pain is caused by an injury or illness that affects the nerve roots innervating the spine as well as the lower limbs, and also pathological invasive innervation within the damaged lumbar discs (Baron et al., 2016).

Within physical assessments, symptoms can be centralized (change in pain along the far end of the entire length of the body region). (A positive test is used to rule out a diagnosis.) Physical examination of the facet joint can also be performed based on centralization and lack of relief from recumbency. The other test is one that centralizes the sacroiliac joint (Peterson et al., 2017). The following test is disc herniation with root involvement, where the dermatological distribution, which mirrors neurological results, improves the set specificity of the outcomes. Spondylolisthesis, fracture, myofascial pain, peripheral nerve, and central sensitization are some of the other tests available.

References

American Association of Neurological Surgeon. (2020). Low Back Strain and Sprain. Retrieved

ans.org/en/Patients/Nrurosurgical-Conditions-and-Treatment/Low-Back-Strain-and-

Sprain#:

Agency for Healthcare Research and Quality (AHRQ). (2016). Noninvasive Treatments for Low

Back Pain: Current State of the Evidence. Retrieved from

https://effectivehealthcare.ahrq.gov/products/bac-pain-treatment/clinician.

Allegri, M., Montella, S., & Slici, F. (2016). Mechanisms of low back pain: a guide for diagnosis

and therapy. F1000 Research. httpS://doi.org/10.12688/f1000research.8105.1

Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017). Lumbar Disc Herniation. Current review

in musculoskeletal medicine, 10(4), 507-516. https://doi.org/10.1007/s12178-017-9441-4

Baron, R., Binder, A., Attal, N., Casale, R., Dickenson, A. H., & Treede, R. D. (2016).

Neuropathic low back pain in clinical practice. European Journal of Pain, 20(6), 861-

873. https://doi.org/10.1002/ejp.838

Genev, I.K., Tobin, M. K., & Zaidi, S. P. (2017). Spinal Compression Fracture Management: A

Review of Current Treatment Strategies and Possible Future Avenues. Global Spine

Journal, 7(1). https://doi.org/10.1055/s-0036-1583288

Peterson, T., Laslett, M., & Juhl, C. (2017). Clinical classification in low back pain: best

Evidence diagnostic rules based on systematic reviews. BMC Musculoskeletal

Disorders, 18(188). https://doi.org/10.1186/s12891-017-1549-6

Wang, F., dong, Z., Li, Y. -P., Miao, D. -C., Wang, L. -F., & Shen, Y. (2019). Wedge-shaped

Vertebrae is a risk factor for symptomatic upper lumbar disc herniation. Journal of

Orthopedic Surgery and Research, 14(1). Retrieved from

https://doi.org.ezp.waldenulibrary.org/10.1186/s130-019-13147

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