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
SUBJECTIVE
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.
OBJECTIVE
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
BreastDeferred.
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

Are you looking for answers to a similar assignment?Nursingstudy.org has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.

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

PICOT Examples

PICOT Question for the Evidence-Based Practice ProjectPICOT Question for the Evidence-Based Practice Project
100 Good Examples Of PICOT Questions & PapersThe post below includes 100 Good Examples of PICOT Questions for NPs and papers in different subject areas such as diabetes, mental health, falls, emergency nursing, pregnancy, hypertension and nursing burnout.
PICOT Question & Literature SearchPICOT Question & Literature Search
Grand Canyon Literature Review PICOT Statement PaperGrand Canyon Literature Review PICOT Statement Paper
 Evidence-Based Practice Project: PICOT Paper SAMPLE Evidence-Based Practice Project: PICOT Paper SAMPLE

Read More:

Discussion 1: Summarize, compare and contrast two of the EBP models to change practice in an organization as listed in Melnyk text – Solution

Discussion 1: Describe your thoughts on the use of middle range nursing theories in relation to nursing practice as compared to the use of other levels of nursing theory – Solution

A Page will cost you $12, however, this varies with your deadline. 

Enjoy the convenience of having a reliable Writer to do your paper at an Affordable Price.  With our premium writing service, you no longer have to spend days and nights meticulously working on your assignment, instead use that time to do other important things. 

Upon completion, we will send the paper to you via email and in the format you prefer (word, pdf or ppt). 

Yes, we have an unlimited revision policy. If you need a comma removed, we will do that for you in less than 6 hours, if you need a full paper review we are always available to handle your request. 

As you Share your instructions with us, there’s a section that allows you to attach as any files. Please include all the details and files useful to the writer. You can also provide a sample of your work, so that the writer can write just like you!

Yes, through email and messages, we will keep you updated on the progress of your paper. 

Start by filling this short order form nursingstudy.org/order

And then follow the progressive flow. 

Having an issue, chat with customer support online

Regards,

Cathy, CS. 

Tags:

Do you need to write an original paper?

How much will this cost me?

A Page will cost you $10, however, this varies with your deadline.
We understand that you are paying for a near-perfect paper and the time convenience, and are committed to delivering even better.

Who will write my paper?

We source the best talent globally. Our experts are based in the USA, UK, Australia and elsewhere. Our recruitment process is rigorous with only 2 out of every 100 candidates getting accepted into our expert cohort.

Our qualified editors and managers provide constructive feedback, point out mistakes, and remind our writers about the pre-conditions and instructions to follow!

How can you help me with my assignments?

Yes, at Nursingstudy.org you’ll find a Perfect and Reliable Academic Writer at an Affordable Price.

Nursingstudy.org is a site born out of the necessity to help out continuing and practice nurses with their nursing assignments, Not because they do not know how to, but to create time for them.

What If I don’t like the delivered paper?

We pride ourselves on offering a quality service. If you are unhappy with a completed order or would like something changed, we offer unlimited revisions for 30 days. Providing us with detailed feedback about the desired changes helps us address the issue fast. Our experts correct any and all mistakes pertaining to the initial service request.

How can I send you all my instructions?

Instructions can be sent to us via message and email or you can call and chat with us. You can also add the instructions here nursingstudy.org/order

Our customer service is available 24/7. We are always here to support you.

blog (854) Study Tips (138)

BSN (31) capstone and practicum reflective journal (2) Chamberlain University (83) Developing Organizational Policies and Practices (2) DNP (36) essay topic selection (3) essay writing (3) essy writing guides (3) Grand Canyon University (8) Grand Canyon University Walden University (83) Herzing University (82) how to help vulnerable populations (2) MSN (19) nursing essays (19) nursing papers (20) PMHNP Assignments (8) solved essays (19) Walden University (14) who can write my essay (3) write my essay (3)