Episodic/Focused SOAP Note

Patient Data:

Name; JIK

Age; 42

Sex; Male

Nationality; Caucasian

SUBJECTIVE

Chief Complaint; "I have low back pain."

HIP

A 42-year-old Caucasian male came into the office this morning with chronic back pain. The pain started about a month ago. The pain is described as gloomy and sore muscles, with a sharp hunting pain down his left leg. The pain comes and goes and is worse at bedtime. When he is at rest, he rates the pain as a 4/10, but when he is moving or standing, he rates it as a 10/10. He also reports that the pain creates a loss of sensation in his left foot and itchiness in his left bottom. Three ibuprofen and claims furnished little to no recovery (Bohinski, R. (2018).

Prevailing Medication: OTC Ibuprofen 200mg oral tablet, three tablets were taken this morning. Once a day, take a 40mg tablet of lisinopril. At night, take a Lipitor 40 mg tablet.

FamHx:

Sister, age 40, no available ailments

Three children, intervals 13, 10, and 8, with no available ailments

Mother, age 73, hyperlipidemia DM2

Brother, age 45, HTN

Grandparents' departed incentives unspecified

Father, age 75, HTN

PMHX: Immunizations are constantly updated, and this season's flu vaccine was also provided. 2016 Tdap Hypertension and hyperlipidemia Negates any surgical procedures. Negates any previous record of collisions, injuries, or plunges.

Allergies: NKDA

Soc Hx: 40+ hours per week as an operations manager. Fifteen years married, three kids (2 girls, one boy). Denies smoking and using drugs; drinks frequently. He says he doesn't exercise but is on his feet all day. He and his wife own a home in a housing complex. He enjoys golf.

System evaluation

1. Gastrointestinal: Defends against vomiting and diarrhea. Disregards bowel variations, diarrhea, or upset stomach. He adamantly denies abdominal pain.

2. Respiratory: refuses to acknowledge difficulty breathing, coughing, or respiratory secretions production.

3. Cardiovascular:...…spot in the centerenging outer wall (Bohinski, 2018).

Diagnostic Testing

Diagnostic testing will be required in this case of back pain for appropriate treatment. Before reaching the final diagnosis, I'd like to get the results of any screening procedures. The preliminary testing I'd like to do will be the least disruptive and most cost-effective.

Sed rate and CBC-It It may not be essential, but a white blood quantity with no leukocytes will be enhanced, which can help identify an infection present.

X-rays can help determine whether the bony cartilages in the spine are too close together and whether there are arthritic modifications, bone spurs, or injury.

Nerve Conduction Studies and Electromyography (EMG) (NCS)-Electromyography (EMG) can detect electrical impulses in the muscles. NCS is capable of detecting injury and muscle spasms.

CT (Computerized Tomography) scan- This is critical in identifying whether or not there is a lumbosacral disc injury.

Reference

Bohinski, R. (2018). Herniated lumbar disc.…