nursing

The attach is sample SOAP NOTE , pls rewite with zero turnitin

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LowerBack SOAP Note

United State University

Common illness Across the Lifespan-Clinical Practicum

FNP 592

Lower Back SOAP Note

SUBJECTIVE DATA

ID:

Client’s Initials: M.K Age: 45 Race: Caucasian Gender: Female Date of Birth: 6/15/1976 Insurance: covered Marital Status: single

CC: “I’ve been having some pain at my lower back for the last 2 weeks”

HPI: Mrs. K. is a beautiful 45-year-old lady who visited the clinic accompanied with her friend with complaints of lower back pain. For the last two weeks, she’s been experiencing pain that has become worse. Her hips and lower back ache with a dull ache that spreads sporadically. The pain was at first sporadic but has now become persistent. Her lower legs are hurting, she claims. Before now, she has never had any of these symptoms before. Even at its worst, the agony only gets a 5 out of 10. Her pain is alleviated by taking ibuprofen, but activity causes it to worsen. She dismisses the possibility that a mishap or a tragic incident may have resulted in the agony she is now undergoing. The symptoms of night sweats, chills or a fever are not present. The patient verbalized that other than the present conditions, she is in overall good health.

Past Medical History (PMI):

Illnesses/Injuries: During her childhood she was diagnosed with varicella. She has been treating

HBP, allergic rhinitis and hyperlipidemia.

Hospitalizations/Surgeries: She has undergone for surgeries like open cholecystectomy, Abdominal hysterectomy, and Left knee arthroscopy.

Vaccinations: Up to date with her immunizations.

Health Maintenance: Pap smears were last performed in 1995, and her last mammogram was in July of this year. Last pelvic exam was in 2018. The results of her most recent colonoscopy, performed in 2017, were normal.

Allergies: NKDA

Medications:

Take one capsule of a multivitamin orally twice a day.

1200 mg of fish oil orally every day.

Simvastatin 20 mg p.o. every day.

Family History: The patient denies having a stroke illness. Her father died of diabetes, hypertension, and heart disease at 68 years. Her mother, who is still living, is taking care of her high blood pressure and lung problems. Paternal grandfather deceased at 95 years while paternal mother deceased at 91 years. Her maternal grandfather deceased at the age of 80 due to complications of Alzheimer’s from comorbidities.

Social History: For the last 12 years, she has been divorced, and she has one live kid and one dead child, both of whom died from bacterial meningitis. Assistant manager for a storage company: she’s, her boss. Tobacco: The patient is an ex-smoker. For the last 20 years, she smoked one pack a week. In January 1990, she gave up smoking. ETOH: social/weekly takes a list of illegal drugs: Takes 3-4 cups of coffee a day and denies taking caffeine. She is sexually active; have one current boyfriend and they use condoms as primary contraceptive. She is a Christian, and she attends church services every Sunday.

ROS

General: Mrs. K. denies fever, nausea, vomiting, changes in appetite, diarrhea, or chills.

Eyes: Denies clouded vision or sudden shifts in eyesight.

Ears/Nose/Mouth/Throat: There is no evidence that rhinorrhea, a runny nose and sneezing symptoms of a cold or flu are present.

Cardiovascular: HTN, angina, dyspnea on exercise, palpitations, orthopnea and edema are all denied by the patient.

Gastrointestinal: Abdominal discomfort or blood in her feces are not on her list of symptoms.

Genitourinary: Denies urinary frequency, burning, or change in urine color.

Musculoskeletal: Lower back discomfort and restricted range of motion are reported as symptoms. Muscle and joint stiffness are a thing of the past.

Integumentary & breast: Pain, swelling, and discharge are all denied by this patient. Neither her own nor her ancestors’ histories of breast cancer have been mentioned in her assessment. She goes for breasts screening every month.

Neurological: Difficulty in concentrating and poor balance are among the symptoms that the patient denies, as well as numbness, inability to talk and falling down. Other symptoms that were negative include tingling, short-term paralysis and vision problems. 

Psychiatric: denies having suicidal thoughts, insomnia, or anxiety.

Endocrine: Denies excessive thirst, excessive sweating, hunger, or heat or cold intolerance.

Hematologic/Lymphatic: Swelling of lymph nodes, and bleeding disorders are all denied by the patient.

Allergic/Immunologic: NKDA

Objective

Vital Signs: HR:77 BP:112/83 Temp: 98.2 F RR: 18 SpO2: 98% RA Pain: 5/10 Height: 60 inches Weight: 160lbs BMI: 31 (CDC BMI-for-age growth tables show that a person is deemed obese if their BMI is at or above the 95th percentile (Martsolf et al., 2019).

Physical Exam:

Inspection:

General Appearance: A well-groomed, obese, and healthy-looking woman of Caucasian descent.

Skin: No rashes or sores on the skin, no skin twitching.

Skin: Warm and dry with no suspicion or lesions.

Gastrointestinal: The patient had normal bowel sound in all her four quadrants with no tenderness upon palpation. No organomegaly, multitudes or hepatosplenomegaly.

Genitourinary: the patient’s bladder is non-distended with no irritation discovered at her vaginal area. The patient perineal area was moist with no lesions, there was no difficulty urinating or sign of urinary tract infection noted.

Musculoskeletal: Mrs. K. was noted with some discomfort and grimacing during examination and her pain behavior and pathology was distinguished by distraction.

Palpitation: patient’s spine and paravertebral structures was palpated and there was a discomfort and tenderness noted over her lower back and her upper buttocks.

Extremities: Mrs. K. peripheral pulses were palpable.

Range of motion: Patient pain was increased with flexion.

Neurological: speech was clear and logical where she employed a logical tone upon responding to queries. She was also negative for abnormal reflexes.

Psychiatric: Alert and oriented where her respond to queries were logically thought out.

Assessment

Differentials:

1. Lumbar radiculopathy (ICD 10: M54.16)

Sciatica is a symptom of lumbar radiculopathy, which is caused by nerve entrapment. Lower extremity discomfort may be either unilateral or bilateral. It is possible for the symptoms to be acute or persistent. While sitting or standing or coughing or sneezing might exacerbate the discomfort, it typically radiates down from the buttocks to the posterior or posterolateral leg to the ankle or foot (Berry et al., 2019). Supine and crossed straight leg lift tests should be performed during a physical examination to detect nerve entrapment. It is possible to utilize muscle relaxers for up to ten days. If the symptoms continue, diagnostic tests, such as lumbar and sacral x-rays and MRIs of the lumbar and sacral spine, should be performed.

2.

Spinal stenosis (ICD 10: M48.07)

As the spinal canal becomes smaller, the pressure on the spinal cord increases. spinal stenosis in the lower back may cause symptoms like numbness or tingling in one or both legs, weakness in one or both legs and cramping of one or both legs while standing for lengthy periods of time (Wei et al., 2021). The strain on the spinal canal/nerve root may cause bowel or bladder problems in patients. The patient’s gut and bladder are functioning normally. In her lower back, she claims to be experiencing agony that extends down her legs. When she bends forward, she is in agony. On the test, Romberg had a negative indication. An MRI scan should be ordered if a diagnosis of spinal stenosis is suspected (Wei et al., 2021). Patients with spinal stenosis do not satisfy the diagnostic criteria.

3.

Abdominal aortic aneurysm (ICD 10: I71.4)

Schreiber (2018) says that a weak, bulging region in the abdominal wall is an abdominal aneurysm (p. 254). If a patient has an aneurysm, they may not realize it for the rest of their lives. In most cases, they are discovered when a patient is being scanned for another condition. According to Schreiber (2018), a rupture of an abdominal aortic aneurysm may cause rapid, acute stomach pain and lower back discomfort. Aneurysm location and size may be determined using diagnostic techniques such as duplex ultrasound and computed tomography (CT) scanning with contrast (p. 255). These people need to be sent to the emergency room as soon as possible. An abdominal aortic aneurysm is not present in this patient. She insists that she is not experiencing any discomfort in her abdomen. A pulsing sensation in her abdomen is not there, and there is no bruit on examination.

Diagnosis (Lumbar radiculopathy (ICD 10: M54.16)

Plan

A. Diagnostics: Lumbar radiculopathy (ICD 10: M54.16)

a) Treatment: NSAIDS such as Ibuprofen 800 mg PO TID x 3 days are part of the treatment regimen.

b) Education: NSAIDS and grading of exercise are discussed with the patient, as well as their usage in the event of a flare-up. The patient is advised to call the clinic if her symptoms change or worsens. It also suggested that she take NSAIDS on a regular basis while also increasing her daily hydration intake and keeping an eye out for any signs of a GI bleed (Berry et al., 2019).

c) Follow Up: After the drug trial is finished, the patient should return for a reassessment in four weeks.

B. Diagnostics: Spinal stenosis (ICD 10: M48.07)

a) Treatment: Aspirin and ibuprofen are examples of over-the-counter drugs. Additionally, Mrs. K should use hot or cold packs to alleviate her discomfort.

b) Education: Downhill ambulation and excessive lumbar extension and should be avoided by Mrs. K. because they are aggravating factors (Wei et al., 2021).

c) Follow Up: Mrs. K. should visit the clinic if any of the prescription drugs cause an adverse reaction. The patient should attend outpatient physical therapy sessions at the clinic for the following six months to learn how to move appropriately.

C. Diagnostics: Abdominal aortic aneurysm (ICD 10: I71.4)

a) Treatment: Perform a lower limb ultrasound.

b) Education: In order to assist her prevent slouching or forward bending, the physical therapist teaches the patient about joint mobility.

c) Follow Up: Every six to 12 months, Mrs. K will get an ultrasound or computed tomography scan.

References

Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A review of lumbar radiculopathy, diagnosis, and treatment. Cureus, 11(10).

Martsolf, G. R., Barnes, H., Richards, M. R., Ray, K. N., Brom, H. M., & McHugh, M. D. (2018). Employment of advanced practice clinicians in physician practices. JAMA Internal Medicine, 178(7), 988-990.

Schreiber, M. (2018). Abdominal aortic aneurysm. MEDSURG Nursing, 27(4), 254-256. Retrieved from https://search-ebscohost-com.arbor.idm.oclc.org/login.aspx?direct= true&db=ccm&AN=131366468&site=ehost-live&scope=site.

Wei, F. L., Zhou, C. P., Liu, R., Zhu, K. L., Du, M. R., Gao, H. R., … & Qian, J. X. (2021). Management for lumbar spinal stenosis: a network meta-analysis and systematic review. International Journal of Surgery, 85, 19-28.