Episodic and Focused SOAP Note

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: Provides a healthcare history of hypertension and hyperlipidemia. Denies any heart problems, force, or distress. He denies having irregular heartbeats. Denies having edema.

4. Neurological: Refuses to acknowledge migraine, lightheadedness, or loss of consciousness. Paresthesias and prickling in the left leg and foot are reported. Denies having had a brain hemorrhage or epilepsy in the past.

5. Musculoskeletal: Lower back pain that emanates to the left leg is reported. Due to pain, the patient cannot flex, deform, or turn. Denies having had any latest plunges  (Hill, E. (2018).

OBJECTIVE 

Physical exam; 

Neck: Carotids usual, no bruit or carotid artery vein edema.

HEENT: Normocephalic/nontraumatic PERRLA, Ears: standard presentation, clear larynx vesicles, good hearing. Throat: pink, wet mucous membranes with no irritation or nodules.

Point of fact: AAO X 4 is well-dressed and well-fed. There are no odors. There is no apparent distress. Gait is normal. It is explicitly assigned to be causing anguish.

Signs of life: Oral temperature of 98.4F Heart rate 78, blood pressure 155/83, left arm, sitting Non-labored respiration rate of 19 percent, SpO2 of 98 percent on room air Pain: 8/10, weight: 255 lbs, height: 5\\\\\\\'11\\\\\\\", BMI: 35.6

Integumentary: Dehydrate, warm, and silky. Skin turgidity is excellent. There is no excessive perspiration. The color is consistent throughout. Pink and healthy nail beds

Vascular Periphery: S1, S2, RRR; pulses+2 bilat pedal and +2 radial; no gurgling, knead, or scoot. There is no edema, varicosities, or hemoptysis.

Chest/Lungs: A&P bilaterally evident. No congestion, rhinorrhea, or coughing.

ASSESSMENT

Diagnosis 

Radiculopathy- According to Georgia, 2016, he defines radiculopathy as   a condition caused by a compressed nerve in the spine that causes pain, numbness, tingling, or weakness

Differential Diagnosis

According to Hill, 2018, mechanical low back pain originates in the spine, intervertebral discs, or connective tissue.

Degenerative disc disease is characterized by acute spine and neck pain due to disc structural damage. In addition, it damages the immune system and causes burning pains in the hands and feet of some people

Chronic pain with occasional severe pain is indicative (McHugh, B. (2017).

The lumbar herniated disc happens when the gel-like center of a lumbar disc ruptures through a weak spot in the centerenging outer wall (Bohinski, 2018).