Episodic/Focused SOAP Note for Case #1 Back pain Patient Information: Initials, Age, Sex, Race John Doe is a 42-year-old white male. S. CC “Pain in the lower back for the past month.”

 
Episodic/Focused SOAP Note for Case #1 Back pain
Patient Information:

Initials, Age, Sex, Race

John Doe is a 42-year-old white male.

S.

CC “Pain in the lower back for the past month.”

HPI: John Doe is a 42-year-old white male who came to the clinic complaining of lower back pain for the past month. He notes that sometimes the pain radiates to his left leg. The pain started after sitting for 16 hours balancing his company’s budget five weeks ago. The pain often become sudden and make his legs weak. He has not taken any medication to alleviate the pain. He says that the severity of the pain can be scaled in a scale of 7/10.

Current Medications: No medications.

Allergies: No allergies.

PMHx: His pneumonia, influenza, and tetanus vaccines are up to date. The patient has no major medical condition.
Soc Hx: He married with three kids and likes listening to music and watching movies at his free time. He has been smoking two packets of cigarettes for the past 15 years. He denies alcohol use.

Fam Hx: His mother died aged 73 with type two diabetes. His father is alive but has heart problems. His other two younger siblings are healthy. His children are also healthy with no major conditions.

ROS:

GENERAL:  No chill, fever, fatigue, or weight loss.

HEENT:  Eyes:  No visual issues. Ears, Nose, Throat:  No hearing problems, sneezing, runny nose, or sore throat.

CARDIOVASCULAR:  No edema, chest pain, or palpitations.

RESPIRATORY:  No sputum, breathing problems, or cough.

GASTROINTESTINAL:  Reports pain in the lower back.

NEUROLOGICAL:  Reports occasional numbness or tingling of the leg extremities.

MUSCULOSKELETAL:  Reports pain in the lower back muscles

O.

Physical exam:

Constitutional: General Appearance: Healthy appearing adult male with moderate distress. Answers questions properly and is oriented and alert. Vitals: BP 136/90; P 88; R 20; T 36.3; W 92kgs; H 156cm.

HEENT: Head: Hair evenly distributed and head id normal cephalic. Eyes:  Extraocular movements intact, conjunctivae pink. Ears: Hearing intact, clear tympanic membranes on otoscopic. Nose: Clear mucus. Mouth: All teeth are present and in good shape. Throat: Tonsils are not swollen and have no lesions.

Heart: Regular rhythm and rate. No rubs or murmurs. Neck arteries have normal pulse.

Lungs: Chest walls are symmetric. Lungs are bilateral and clear to auscultation. Respiration easy and regular.

Abdomen: Positive straight leg test, no back tenderness, intact bilateral hip motion, unremarkable sensation and strength, negative crossed straight leg test. lumber spine is symmetrical.

Diagnostic results: The condition can be diagnosed using X-ray. Ball, Dains, Flynn, Solomon & Stewart (2019) note that X-ray can show the bone spur that may be pressing the nerve.

X-ray-Pending

A.

Differential Diagnoses

Sciatica:

Sciatica is the primary diagnosis for this case. sciatica is the pain that radiates along the sciatic nerve path, that branches to the lower back through the hips, down to the buttocks and legs (Stynes, Konstantinou, Ogollah, Hay & Dunn, 2018). The disease can also cause muscle weakness and tingling of the one or both legs.

This disease has been selected as the primary diagnosis because the patient feels pain in the lower back that radiates down to the left leg. Physical exam also shows that the patient might have sciatica. He is also obese, hence risks suffering the disease. Stynes et al. (2018) note that excess body weight can cause spinal changes that trigger the disease by increasing stress on the spine.

Lower Back Strain and Sprain:

This disease is one of the most common causes of lower back pain. One of its symptoms include lower back pain that radiate into to buttock but does not impact the legs (Dains, Baumann & Scheibel, 2019). The disease has been included in the diagnosis because the patient feels lower back pain. However, it has been excluded because it does not affect the legs.

Left-Sided Ulcerative Colitis:

Left-Sided Ulcerative Colitis is a disease that causes lasting inflammation and ulcers in the digestive tract (Sahami et al., 2017)). The disease can cause lower back pain that affects the left leg, and that is way the disease has been included in the diagnosis. However, it is not a primary diagnosis because the patient has no fever, diarrhea, or urgency to defecate.

Acute Severe Ulcerative Colitis:

Acute severe ulcerative colitis is characterized by the present of more than six bloody stool along with fever, and diarrhea. This disease also causes back pain that is so severe (Sahami et al., 2017). The disease has not a primary diagnosis because the patient id not bleeding.

Crohn’s Disease:

Crohn’s disease is an IBD that impacts the digestive tract by inflaming the digestive organs, hence leading to back pain, and that is why it has been included in the diagnosis (Rosen et al., 2017). However, it is not a primary diagnosis because the patient has no fever or digestive problems.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Rosen, M. J., Karns, R., Vallance, J. E., Bezold, R., Waddell, A., Collins, M. H., … & Baker, S. S. (2017). Mucosal expression of type 2 and type 17 immune response genes distinguishes ulcerative colitis from colon-only Crohn’s disease in treatment-naive pediatric patients. Gastroenterology, 152(6), 1345-1357. https://doi.org/10.1053/j.gastro.2017.01.016

Sahami, S., Konté, K., Buskens, C. J., Tanis, P. J., Löwenberg, M., Ponsioen, C. J., … & D’Haens, G. R. (2017). Risk factors for proximal disease extension and colectomy in left-sided ulcerative colitis. United European gastroenterology journal, 5(4), 554-562. https://doi.org/10.1177%2F2050640616679552