Unit 7 SOAP: 54 yo female with low back pain radiating to left leg – Solution

Unit 7 SOAP: 54 yo female with low back pain radiating to left leg

Name:  XXX Pt. Encounter Number: XXXX
Date: 9/13/22Age: 54Sex: Female
CC: “low back pain radiating to left leg” 
HPI: 54 yo female presents to the office today c/o lower back pain radiating down L buttock, down the left leg through the calf. Began 3 days ago, with sudden onset while she was at work, following lifting and turning a patient.. She reports feeling a “pop” followed immediately by this pain. States the pain is constant and worsening and rates severity as 7/10. Describes the pain as throbbing, with stinging and tingling down the left leg and calf and reports she “feels crooked”. She has tried rest and Ibuprofen to treat the pain but has gotten no relief. She reports sitting worsens the pain and she is unable to walk without pain. Denies history of similar symptoms. No recent trauma. No previous treatment or testing related to this problem.
Medications: Ibuprofen 400mg as needed for back pain 
Allergies: NKDA Medication Intolerances: none reported
Past Medical History: Uterine fibroids Chronic Illnesses/Major traumas: denies Hospitalizations/Surgeries: 3 live births, partial hysterectomy due to uterine fibroidsPreventive : Immunizations up to date .Tdap 2015, Flu 2019, COVID #1 Jan 2020, COVID#2 Feb 2020. Yearly dental exam. Mammogram March 2020.
Family HistoryMother deceased due to COVID with history of asthma and smoking. Father living, age 86, HTN-controlled, smoker, depression. 
Social HistoryPt attended tech school and is working full time as a nursing assistant. Married and monogamous with husband. She has 3 children. Owns home and feels safe there. Denies smoking, tobacco or recreational drug use. Reports occasional use of wine. ROS Student to ask each of these questions to the patient: “Have you had any…..”GeneralDenies weight change, fatigue, fever, chills, night sweats, or change in energy level CardiovascularDenies chest pain, palpitations, edema.  
SkinDenies rashes, bruises or bleeding, or change in skin lesions.  RespiratoryDenies cough, SOB. 
EyesDenies visual changes GastrointestinalDenies abdominal pain, N/V/D, constipation, eating disorders or ulcer 
EarsDenies ear pain or hearing loss. Genitourinary/GynecologicalDenies dysuria or incontinence. Reports last PAP 2010, normal. 3 live births. 
Nose/Mouth/ThroatDenies congestion or sinus problems. Denies nosebleed. Denies dental disease. Denies sore throat or hoarseness MusculoskeletalReports throbbing lower back pain, radiates to Left buttock and down to left leg/calf for 3 days. Worsening and causing pain when ambulating. Not relieved by rest, position change or Ibuprofen. Denies history of similar problems. Denies joint swelling or history of arthritis.
BreastReports regular SBE, Denies lumps or mass. Last mammogram March 2020NeurologicalAlert and oriented x 4. Denies syncope, seizures. Reports stinging and tingling down left calf but denies numbness.
Heme/Lymph/EndoDenies swollen or painful nodes, denies temperature intolerance, night sweats .PsychiatricDenies depression. Reports anxiety and feeling overwhelmed, but no previous evaluation or treatment. States she self-medicates with exercise or occasional wine.
Weight     110lbs   BMI 17.8Temp 98.3BP 115/80 left, 116/82 right
Height 5’6’’Pulse 76Resp 24 O2 sat 99%
General AppearanceHealthy-appearing adult female in no acute distress.
SkinSkin warm, dry, clean, and intact. No rashes or lesions noted.
HEENTHead is normocephalic, atraumatic.. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TM pearly gray, no bulging. Nose: Nasal mucosa pink; normal turbinates. Neck: Supple. Full ROM. No lymphadenopathy. Oral mucosa, pink and moist. Teeth are in good repair.
CardiovascularS1, S2 with regular rate and rhythm. No clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.
RespiratorySymmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
GastrointestinalBS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly
GenitourinaryNo CVA tenderness. No incontinence during visit.
MusculoskeletalReduced forward flexion of lumbar spine. Left straight leg raise limited to 45 degrees. Left leg sciatic stretch test positive. Reduced response to light touch and pin prick lateral and dorsal left calf. Grade 4 weakness on dorsiflexion of left foot. Reduced right ankle jerk reflex. Negative reversed straight leg raise. Normal curvature of cervical, thoracic and lumbar spine. Gait slow and guarded. Spinal processes nontender. On standing, left shoulder appears higher than right. Full ROM of upper extremities.
NeurologicalOriented x 4 and answers questions appropriately. Speech clear.
PsychiatricMaintains eye contact. Speech is of normal rate and cadence. Normal mood and affect.
Lab Tests/ImagingMRI- normalXray- normal Assessment· Include at least three differential diagnoses-acute low back pain, sciatica, herniated disc· Provide rationale for each differential diagnosis· Final diagnosis -Acute low back pain, sciatica· Pathophysiology of primary and rationale for choosing as finalPlan· Medications· Non-pharmacological recommendations· Diagnostic tests· Patient education· Culture considerations· Health promotion· Referrals· Follow up

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Unit 7 soap: 54 yo female with low back pain radiating to left leg
Unit 7 SOAP: 54 yo female with low back pain radiating to left leg

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Cathy, CS.