Assessing musculoskeletal pain-Focused SOAP Note discussion
Assessing musculoskeletal pain-Focused SOAP Note discussion
Subjective data
Patient particulars
Initials: E.R
Age: 42years
Gender: male
Chief complaint: lower back pain for one month
History of the presenting complaint: E.R is a 42 years old male with complaints of lower back pain for one month. The pain is of acute onset, sharp, and is located at the central region of the spine. It radiates to the left leg and is intermittent in nature, aggravated by thoracic bending and at the beginning of movement. The pain is relieved by walking around and engaging in activities. The patient reports that the pain is associated with weakness of the affected limb, muscle spasms, and numbness. However, the patient denies of abdominal cramping, fever, fatigue, weight loss, and night sweats. Assessing musculoskeletal pain-Focused SOAP Note discussion
BUY NOW A PLAGIARISM-FREE PAPER HERE
Past medical history: the patient has had diabetes mellitus for three years. He has a history of left knee join fracture ten years ago through a road traffic accident.
Current medication: metformin 500mg BD
Immunization: it is up to date
Allergies: none
Social history: E.R is a lecturer at the school of health sciences. He is married and has two children. He smokes cigarettes and drinks alcohol occasionally. He does not engage in physical exercises.
Family history: E.R is the firstborn in his family. His siblings and parents are alive.
His mother has hypertension and diabetes mellitus and his father has diabetes mellitus. His younger sister is 36years old and has hypertension and diabetes.
Review of systems
General: the patient denies headache, malaise, fever, and night sweats.
Cardiovascular: the patient denies chest pain, dizziness, syncope, orthopnea, and palpitation.
Respiratory: the patient denies coughing, breathlessness, wheezing, and sputum production.
Gastrointestinal: the patient denies abdominal pain, constipation, diarrhea, vomiting, and nausea.
Genitourinary system: the patient denies dysuria, hematuria, polyuria, and urine incontinence.
Objective data
General: the patient is alert and oriented. He is well kempt and maintains eye contact. He has no pallor, jaundice, lymphadenopathy, and edema.
Vitals: the patient’s blood pressure is at 134/78mmHg, pulse rate at 78bpm, height at 150cm, weight at 68kgs, and BMI at 30kg/m2.
Musculoskeletal: the patient has an upright gait and posture. The range of motion is normal at the time of examination. He is not limping and has no pain. The lower back is normal; there is no kyphosis or scoliosis. Upon palpation of the lower back, there is tenderness at the sciatic notch. Straight leg raising tests induces the pain. There is a weak dorsiflexion of the great toes.
Abdominal: the abdomen is round with uniform skin color. The bowel sounds are present at the four quadrants. There is a tympanic percussion note. There is no tenderness, shifting dullness, and fluid thrills. There is no tenderness and organ enlargement.
Assessment
The patient complaints of lower back pain radiating to the left leg. He has diabetes mellitus, has a positive history of knee joint fracture, he smokes cigarettes, and leads a sedentary lifestyle. The patient’s differential diagnoses are sciatica, spondylosis, and lumbar disc disease. The diagnostic tests for this patient are lumbar sacral radiograph, MRI, and CT scan. In addition, some maneuvers such as lumbar lateral bending, hip flexion, knee extension, and foot dorsiflexion helps in determining the five nerve roots in sciatica. Assessing musculoskeletal pain-Focused SOAP Note discussion
Sciatica is musculoskeletal disease due to irritation of the sciatic nerve at the pelvic and sacral region. The presenting signs and symptoms are severe lower back pain radiating to the leg region. The pain is a result irritation of the sciatic nerve through hip flexion, and dorsiflexion of the ankle in an extended knee joint (Kongsted, et al, 2019). This is the most probable diagnosis for this patient because of the presenting symptoms, physical findings, and risk factors.
Lumbar spondylosis is a condition characterized by new bone formation at the margins of the vertebral bodies (Kahn, et al, 2021). It is characterized by lower back pain radiating to the lower extremities associated with muscle weakness and numbness.
Lumbar disc disease is due to disc herniation at the vertebral spine. Disc herniation irritates the displaced nerve root causing persistent severe lower back pain (Mowforth, et al, 2021). it is common in patients with pre-existing back pain. However, the pain radiates up to the thighs but does not radiate below the knees
| Focused SOAP Note for a patient with chest pain
S. HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70” General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the Assessing musculoskeletal pain-Focused SOAP Note discussion second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary– Lungs are clear to auscultation and percussion bilaterally BUY NOW A PLAGIARISM-FREE PAPER HEREDiagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction |
- This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform? Assessing musculoskeletal pain-Focused SOAP Note discussion
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Assessing musculoskeletal pain-Focused SOAP Note discussion.
