WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

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WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Response #1

Instructions: Just need a response to Gert Marais Post (feedback)

 

Gert Marais 

Back Pain “Initial Post”

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Episodic/Focused SOAP Note Back Pain

 

Patient Information:

J.M, 42 y.o, Male, Caucasian

S.

CC (Lower Back Pain) “Something is wrong with my back”

HPI: 42 y.o male comes in today for with complaints of lower back pain for a month now. Patient says “he was doing landscaping and shoveling dirt when he felt a sharp shock of pain in his back and it caused him to drop to his knees.

The pain subsided some but his back became tight and caused both his hamstrings to cramp up if he tried to stretch his back, and sometimes a sharp shock feeling goes down his left hip to the back of his left leg and into his calf”.

Patient rates worst pain to be 8/10 in his lower back and 5/10 in his left leg. Patient states the pain never drops below 3/10 and intense pain last a few seconds to a few minutes.

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Patient says warm showers and rest seem to work the best and ibuprofen and Tylenol does not seem to help. Patient says he cannot tolerate holding weight and cannot seem to bend backwards without a sharp sock going down his lower back and left leg. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Current Medications:

1.)    Ibuprofen 800 mg PO Q6hr PRN for pain.

2.)    Tylenol 600mg PO Q4 PRN for pain

Allergies:

Medication Allergy: Denies

  •             Food Allergy: Denies
  •             Environmental Allergy: Bee stings: Moderate swelling to limb. Denies respiratory distress.

Past Medical History: Denies medical history “I have always been a healthy guy, heck I hardly get sick. I did break my left arm in football when I was a freshman in high school”

Past Surgical History (PSH):

1.)    Appendectomy age 10.

Sexual/Reproductive History: “I am married and devoted to my wife. We have been married for 15 years and we are not worried about sexual diseases, and we do not have any sexual diseases”.

 Personal/Social History: Denies smoking “I have never smoked in my life”. Endorses seldom use of ETOH consumption “I probably drink maybe 5 beers in total a year”.

Denies illicit drug use “I have always had a good head on my shoulders, I never got involved with that stuff”. Patient states he does heavy weightlifting since high school and has not been able to do any cardo or lifting since his back injury”.

Patient states “I purposely gain or lose weight for lifting purposes, but recently I have been gaining a bit more weight and finding it harder to lose weight”. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Patient states his diet is mostly fish, chicken, rice, and occasional red meats. Patient states married only once and have an 8 y.o son. Patient denies risky behavior, activities.

Patient states he lives in a “good neighborhood with plenty of fresh air”.

Immunization History: Patient states “I should be up to date on shots, I have my immunizations reviewed about twice a year with my checkups”

1.)    Denies ever receiving covid-19 vaccine

2.)    States “I just got my flu shot last month”

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included.

Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

  • 1  Father: Inguinal hernia age 35. Died of car accident age 42.
  • 2   Mother: Died of breast cancer age 32.
  • 3 Brother: “He is struggling with weight, but he is active and healthy otherwise” age 45.
  • 4  Sister: “struggling with weight, but active and healthy with 2 kids”. Alive age 38.
  • 5  Maternal grandfather: Died from plane crash age 52.
  • 6   Maternal grandmother: Hypertension. Alive 78.
  • 7   Paternal grandfather: Died from stroke age 75.
  • 8   Paternal grandmother: “Alive and doing well for 81”
  • 9   Son: Healthy age 8

ROS:

GENERAL:  Denies weight loss without trying.  Denies “feeling sick”. Denies fever, chills, weakness or fatigue. Patient states “I am pretty fit and healthy, I just have not been able to do anything since my back injury”.

Cardiovascular/Peripheral Vascular: Denies chest pain/discomfort.  Patient denies concerns about his cardiovascular “I have a healthy heart and I have no concerns with in not working properly”. Denies history of angina after workouts. Denies edema.

Respiratory: Denies shortness of breath/ distress. Patient states “My breathing is excellent and I don’t feel out of breath after doing mild to moderate physical activity”.  Patient states “Before my injury I use to run 3-5 miles a week at moderate speed and walk 3-5 miles as well for cardio”

Gastrointestinal: States last BM “I have daily soft formed stool”. Denies constipation, diarrhea.  Patient states “It is difficult for me to have to sit down and poop because it is painful to try and sit with my back hurting”.

Denies issues with urination/ voiding. Denies N/V. Denies heartburn or GERD. Patient states “I sometimes get hemorrhoids but they are pretty mild and tend to go away”. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Neurological: Endorses sharp pain to his left hip which radiates down to the back of his leg and into his calf. Patient states pain is more intense and sharp when leaning backwards verses more aching and dull pain when leaning forward.

Denies tingling sensation. Patient denies paralysis of extremities.

Musculoskeletal: Patient states “I cannot walk normally and find myself to be off balance because of sudden sharp pains in my back causing me to crumble to my knees”.

Patient states he has to walk slowly with bracing his hips with his hands to try and relieve pain. Patient states he also will have hamstring cramps when trying to get out of bed or moving after resting for a while. Patient denies weakness to extremities.

Patient states “My lower back feels like it starts to tighten and then I feel a tremble followed by pain”. Patient denies budging of the skin, denies notice of masses or protrusions.

Psychiatric: Denies SI/HI/AVH. Rates anxiety moderate “I am worried that I won’t be able to do any physical activity and keep up with my stress relieving coping skills of working out”, rates depression low.

O.

Physical Exam:

Vital signs: BP 128/75 RA sitting. HR 78, RR 16, 99% O2, 36.6C Temp. 89.54Kg, 182.8 cm. 5/10 Pain lower back pain.

General: Patient presents as bright, calm, cooperative, and grimacing intermittently in response to pain in his lower back.  Patient appears healthy. Age appropriate for presentation.

Skin appropriate for ethnicity, no wounds/ sores/rashes/bruises noted. Skin warm, dry, and non-tenting.  Gait abnormal: patient leaning left and forward during gait with intermittent loss of balance in response to pain.

Patient sitting with requiring lower back support, patient shifting in chair. Patient able to stand without support. No weakness noted in extremities, but limited to fully engagement of muscles lower extremities due to pain.

Appropriate hygiene practices, well groomed. Patient is A&Ox4. Patient is engaging with assessment.

Physical exam:

Cardiovascular/Peripheral Vascular:

Chest symmetrical bilaterally, no visible abnormal finding. No edema or swelling noted in extremities. Capillary refill less than 3 seconds for hands and feet.

No abnormal finding with heart auscultation presenting with S1, S2. Femoral arteries palpated +2 expected findings. Popliteal arteries palpated +2 expected findings. Right and left tibial arteries palpated +2 bilaterally expected findings.

Respiratory: Breath sounds present in all areas, no adventitious sounds present.

Gastrointestinal: Abdomen symmetrical, flat contour, with no abnormal findings. Normoactive bowel sounds present in all four quadrants. None tender with light and deep palpitation.

Musculoskeletal: Spine curvature presents as normal with no kyphosis or lack of lower lumbar lordosis. No scoliosis present with patient bending forward.

Spinal pain present with palpation at L4 to S1. Paraspinus muscles presenting with palpation tenderness L3 to L4. Positive tripod sign with left leg being raised and patient eliciting straightened arm and bracing in a triangular position.

Positive Straight leg sign to left leg eliciting pain around 30 to 60 degrees and dorsiflex of foot elicits pain after 15 degree drop to leg. Femoral stretch test for L2 to L4 with mild elicit of pain.

Neurological: Motor strength L4 test: thighs equal in strength. L5 Motor strength test dorsiflex of feet presented with equal strength in both feet.

S1 motor strength test with planter flex of feet: strength equal bilaterally. Feet bilaterally raised when walking on heels, no foot drop noted. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain

Both heels raised with no drop noted when walking on his toes. No noted differences in dermatomes to thighs when assessed with needle.

No noted differences in dermatomes for L5. No noted differences in dermatomes for S1. L4 elicits patellar tendon reflex to left and right leg.

Medial hamstring elicits reflex for right and left leg. Elicit of jerk to Achilles tendon present in both right and left leg.  Neurological exam resulted with no abnormal findings.

Skin: Skin appropriate for race, no wounds/ sores/rashes/bruises noted. Skin warm, dry, non-tenting.

Diagnostic results:

Recommendations for no abnormal findings in neurological exam is not to proceed with imaging at this time, but have the patient come back in 6-8 weeks if symptoms are not improving (Singh, 2020).

  •   CBC to rule out infection: “Complete blood count is ordered along with or prior to the blood culture to determine whether the person has an increased number of white blood cells (or in some cases, a decreased number of white blood cells), indicating a potential infection
  •    C-reactive protein (CRP) level: Helps indicate inflammatory marker in the body (Arthritis Foundation, 2020).

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A.

Differential Diagnoses

  1.  Back sprain: Indicator with mode of injury (physical straining activity) and positive finding with paraspinus muscles presenting with tenderness. Location commonly “Low back, buttock, posterior. Quality of pain: aches/spasms. Aggravating symptoms: increased with activity” (Patel & Ogle, 2000).
  2.   Acute disc herniation: Sharp pain radiating down affected side. “Positive straight leg raise test. Low back to lower leg pain. Sharp shooting or burning pain in leg. Increased pain with bending or sitting” (Patel & Ogle, 2000).
  3.  Spondylolisthesis: Symptoms include “Muscle spasms in the hamstrings, back stiffness, difficulty walking or standing, pain with bending over” (Cleveland Clinic, 2020).
  4.  Infection: “Pain in lumbar spine, sacrum. Pain is sharp and aches” (Patel & Ogle, 2000).
  5.  Inflammatory arthritis: “all arthritis leads to inflammation, arthritis is categorized as inflammatory and noninflammatory (degenerative) based on its origin” (John Hopkins, 2021).  Spinal arthritis can cause “Radiculopathy – pinching of the peripheral nerves as they exit the spine (sciatica is one type of radiculopathy” (John Hopkins, 2021).

 References

Arthritis Foundation. (2020). Blood, Fluid and Tissue Tests for Arthritis. Blood, fluid and tissue tests for arthritis. Retrieved October 21, 2021, from https://www.arthritis.org/health-wellness/about-arthritis/understanding-arthritis/blood,-fluid-and-tissue-tests-for-arthritis.

Cleveland Clinic. (2020, August). Spondylolisthesis: What is it, causes, symptoms & treatment. Cleveland Clinic. Retrieved October 21, 2021, from https://my.clevelandclinic.org/health/diseases/10302-spondylolisthesis.

John Hopkins. (2021, January). Spinal arthritis (arthritis in the back or neck). Johns Hopkins Medicine. Retrieved October 21, 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/spinal-arthritis.

Patel, A., & Ogle, A. (2000, March 15). Diagnosis and management of acute low back pain. American Family Physician. Retrieved October 21, 2021, from https://www.aafp.org/afp/2000/0315/p1779.html.

Singh, B. (2020). Low back exam, approach to. Stanford Medicine 25. Retrieved October 21, 2021, from https://stanfordmedicine25.stanford.edu/the25/BackExam.html. WK8 Discussion Response Episodic/Focused SOAP Note Back Pain