SOAP NOTE Lumbar pain (NURSING MSN5500) Comprehensive Assessment.

SOAP NOTE Name: S.N. Date: Time: 15:20 ID # Age: 75 Sex: Male SUBJECTIVE CC: "I have back pain" HPI: S.N. is a 75years old male, who came to the clinic today complaining of low back pain (5/10), which is exacerbated by physical activity and ambulation, and improves with rest. The pain appeared several days ago, after picking up an object from the ground; it is irradiated to right leg accompanied with numbness. He has been suffering HTN and obesity. He denies smoking, drinking alcohol, or using another illicit drug. Medications: Amlodipine 10 mg 1 tab po daily (antihypertensive) Diovan HTC 80/12.5 mg po daily PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas : Hypertension (401.1) controlled Hospitalizations/Surgeries : none Family History Mother death: Stroke, OA Father death: CDA, HTN, Obesity. Social History The patient graduated from college. Retired. He lives in a residential area with his wife. Denies substance use / abuse, ETOH, tobacco, marijuana. Immunization: Received flu vaccine in November 2015 Environmental hazard: Denies environmental hazard Diet: Drinks natural juices, coffee 1/2 cup every morning, and 8 glasses of water daily. Also eat healthily. Exercise and Leisure: Sedentary life, on weekends makes outdoor activities with his family. Sleep: Insomnia.