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

Solution:Back Pain Case Study

CASE 1

Patient Information: A 36-year-old female

S.

CC: “Constantly feeling tired even after a period of rest.”

HPI: The patient present complains of persistent tiredness even after rest. The patient reports that she lacks energy every day after a day’s job, which began a few months ago but has progressively gotten worse. She reports missing several workdays due to a lack of energy even after showering and dressing for work. She reports sleeping more than eight hours a night while needing several naps throughout the day.  She reports an uncomfortable buzzing sensation traveling from the neck down to the spine with what sounds to be a Lhermitte’s sign. Uses interferon to manage MS, CBD oil to help with energy without relief, and Cetirizine 10 mg PO daily to manage allergies(Back Pain Case Study)

Current Medications:

Interferon to manage MS

CBD oil to help with energy without relief

Cetirizine 10 mg PO daily to manage allergies

Allergies: Nasal congestion.

PMx: Diagnosed with Multiple Sclerosis 3 years ago. Up to date with her pap smear. She goes for a monthly self-breast exam.  Saw her dentist and eye doctor within the last year.

Soc Hx: Has a full-time job. Occasionally drinks wine during the weekend. Denies tobacco or illicit drug use.  

Fam Hx: Married with two children. Her other has diabetes and has hypertension. Farther and siblings are alive and well. She has an aunt diagnosed with MS and is wheelchair-bound. 

ROS:

GENERAL: Denies fever, chills, weight loss, or gain.

HEENT: Face symmetrical.  PERRLA is normal. No retinal hemorrhages or exudates. Reports nasal congestion. Oral mucosa pink and moist(Back Pain Case Study)

SKIN: Dry, warm, and intact

CARDIOVASCULAR:  Heart rate bradycardic. No chest pain, chest pressure, or chest discomfort

RESPIRATORY:  Regular breath. No pauses or extra beats.  

NEUROLOGICAL:  Reports nasal congestion. She denies loss of bowel or bladder. 

MUSCULOSKELETAL: Normal muscle function. Muscle tone palpated. No fasciculation, tenderness or atrophy.  Buzzing sensation in the neck down the spine.

HEMATOLOGIC: Conjunctivae rim pale.

LYMPHATICS:  No lymphadenopathy.(Back Pain Case Study)

PSYCHIATRIC:  No depression or anxiety. No history of splenectomy.

ENDOCRINOLOGIC:  No thyromegaly.

ALLERGIES: Nasal congestion.  

CASE 2

Patient Information: A 35-year-old male

S.

CC: “Acute low back pain.”

HPI: The patient experienced an acute onset of low back pain radiating down the back of the left leg following yard work. The pain has worsened in intensity, and he is having difficulty bearing weight on the leg. The pain ease with Ibuprofen 800mg. Rates pain eight out of 10, described as sharp, lightening sensation. 

Current Medications:

Ibuprofen 800 mg to manage the pain.

PMx: Denies hospitalizations or surgical history. He sees primary care provider when he has an acute issue. 

Soc Hx: Works for IT department from home. Sits about 8 hours per day.  Reports smoking a pack of cigarettes a day ten years but quit five years ago. Currently vapes daily.  He reports one beer with dinner. Denies illicit drug use.

Fam Hx: He recently divorced and shared custody of three children. Denies family history of the spine or musculoskeletal diseases or malignancy.

Health promotion: No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.

ROS:

GENERAL: Denies fever, chills, weight loss, or weight gain.

HEENT:  Eyes:  No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose, or sore throat.(Back Pain Case Study)

SKIN: No rashes or bruising.

CARDIOVASCULAR:  No chest pain, chest pressure, or chest discomfort.

RESPIRATORY:  No shortness of breath, cough, or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting, or diarrhea.

NEUROLOGICAL:  Denies headaches, dizziness. Severe pain with active movement. Minimal pain with passive motion. Denies loss of bowel or bladder or saddle anesthesia.

MUSCULOSKELETAL: Denies history of lower back pain or previous back injury. 

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy

PSYCHIATRIC:  No depression or anxiety(Back Pain Case Study)

ENDOCRINOLOGIC:  ENDOCRINOLOGIC:  No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No NKFDA

CASE 3

Patient Information: An 83-year-old female

S.

CC: “A productive cough.”

HPI: The patient presentsa productive cough for the last three weeks. She reports fever on and off. She has chest pain, which worsens at night. She has a mild sore throat and nasal congestion.

Current Medications:

Guaifenesin to relieve sore throat and nasal congestion.

Tylenol 500 mg PO daily to manage osteoarthritis.

Citalopram 10 mg PO daily to manage depression

Omeprazole 10 mg PO daily to manage GERD(Back Pain Case Study)

Levothyroxine 88 mcg PO daily to manage hypothyroidism

Allergies: Allergy to PCN with the reaction of hives.

PMx: No history of asthma or any chronic lung diseases. Diagnosed with osteoarthritis.  Reports depression and GERD. Reports hypothyroidism. Hospitalized for the birth of three children. Had right knee replacement two years ago

Soc Hx: She lives in a retirement community and uses a rolling walker for long-distance walking and a cane around the house. Denies recent travel. She denies smoking, alcohol, or illicit drug use.

Fam Hx: Her children live close by and help her with errands.  All her children are alive and well, no one with similar symptoms.

Health promotion: Up to date on vaccines, including flu and pneumonia vaccine. She wears her mask when she goes out in public and maintains a physical distance of six feet while practicing good hand hygiene. 

ROS:

GENERAL: Reports fever.

HEENT:  Eyes:  No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat:  Mucous membranes moist.  No tonsillar exudate, oropharynx clear. Nares patent with clear drainage. Reports sore throat and nasal congestion.

SKIN: No rashes or bruising.(Back Pain Case Study)

CARDIOVASCULAR:  Reports chest pain and discomfort.

RESPIRATORY:  Reports excessive cough and occasional wheezing. Irregular heartbeats.

GASTROINTESTINAL:  Denies nausea, vomiting, or diarrhea.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy

PSYCHIATRIC:  Reports depression.

ENDOCRINOLOGIC:  No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No asthma.

CASE 4

Patient Information: A 64-year-old

S.

CC: “fatigue.”

HPI: Routine evaluation. The patient complained of fatigue for the past three months. Reports no change in the diet or lifestyle.

Current Medications: Over-the-counter non-steroidal anti-inflammatory medication (NSAID).

Allergies: No history of allergies.(Back Pain Case Study)

PMx: Denies any past medical history, surgical history, or hospitalizations.

Soc Hx: Retired post office employee. Denies smoking. Reports an occasional beer with friends. Consumes bee three times a day following retirement.

Fam Hx: Reports family history of diabetes, hypertension, cardiac disease, and colon cancer. 

Health promotion: No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.

ROS:

GENERAL: Reports fatigue but denies fever or chills. 4-pound weight loss.

HEENT: Reports lightheadedness. Eyes:  Denies changes in visual. Ears, Nose, Throat:   Denies trouble swallowing.

SKIN: No rashes or bruising.

CARDIOVASCULAR:  Denies chest pain. No palpitations. Chest pressure or chest discomfort.

RESPIRATORY:  No shortness of breath, cough, or sputum.

GASTROINTESTINAL:  Denies nausea or vomiting. No abdominal pain.

GENITOURINARY: Denies urinary frequency, burning, or hematuria.

NEUROLOGICAL:  Reports lightheadedness. Normal bowel movements. Dark bowel movement.

MUSCULOSKELETAL: No suprapubic or CVA tenderness.

HEMATOLOGIC: Paleness of conjunctivae and palmar pallor

LYMPHATICS:  No lymphadenopathy or swelling.

PSYCHIATRIC:  No depression or anxiety(Back Pain Case Study)

ENDOCRINOLOGIC:  Denies cold or heat intolerance. Denies sweating.  

ALLERGIES:  No NKFDA

CASE 5

Patient Information: A 19-year-old female

S.

CC: “headaches frequently.”

HPI:  The patient is a 19-year-old presenting a frequent headache, which has become more debilitating recently. Headache episodes occur at least twice monthly and last for two days. The pain in the right temple or the back of the right eye spreads to the entire scalp for a few hours. The pain is sharp and throbbing. The patient reports severe nausea. Noise and movement aggravate the pain. The pain eases when sleeping in a dark, quiet room.(Back Pain Case Study)

Current Medications: Naproxen and Acetaminophen to manage the pain.

Allergies: Reports no drug allergies but has seasonal and allergies to pet dander.

PMHx: Persistent headaches.

Soc Hx: Is sexually active uses condoms.  Currently a freshman in college.  Denies alcohol, illicit drug, and tobacco use.

Fam Hx: A thorough history reveals her mother suffers from migraines.

Health Promotion: Last health visit was over the summer, up to date on health maintenance for her age. 

ROS:

GENERAL:  She denies fever, chills, night sweats, or neck stiffness. 

HEENT:  Normocephalic Eyes:  She denies visual changes other than photophobia. Normal visual acuity Ears, Nose, and Throat:Mucous membranes pink and dry.

SKIN:  Warm and dry.

CARDIOVASCULAR:  She denies chest pain, palpitations, or edema.

RESPIRATORY:  Denies shortness of breath or cough.(Back Pain Case Study)

GASTROINTESTINAL:  She denies abdominal pain but reports some nausea and vomiting.

GENITOURINARY:  Last menses four weeks ago.

NEUROLOGICAL:  Reports headaches.

MUSCULOSKELETAL:  Normal muscle tone.

HEMATOLOGIC:  No anemia, bleeding, or bruising.

LYMPHATICS:  Reports thyroid enlargement. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  Reports adenopathy.

ALLERGIES:  Reports no drug allergies but has seasonal and allergies to pet dander.

Name:  XXX	Pt. Encounter Number: XXXX
Date: 9/13/22	Age: 54	Sex: 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 2020	NeurologicalAlert 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 17.8	Temp 98.3	BP 115/80 left, 116/82 right
Height 5’6’’	Pulse 76	Resp 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

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