MN 576 Soap Note Low Back Pain- Purdue University

Date and Time of H&P: 5/28/2019, 1:00PM age: 63 DOB: 8/24/1955 Chief Complaint: “I fell two days ago and the left side of my back hurts HPI: Patient is a 63-year-old white Caucasian who presents to the clinic with the complaint of having a recent fall two days ago with moderate to severe back pain. Patient states he was walking in his RV and bumped his foot on a shelf and fell. Patient rates pain a 9 on pain scale. Patient describes pain as aching and states when he moves around the pain worsens. Past Medical History: Anxiety D/O F41.9 Other muscle spasm M62.83 Hypercholesterolemia E18.0 I10 Essential HTN Medications: Buspirone 5mg po daily Clotrimazole 1% BID to affected area HCTZ 25mg po daily Iron Ferrous Sulfate 325mg po daily Losartan 50mg po daily Percocet 5-325mg po daily TID as needed Injury: Gun shot wound left leg 1975, work injury to back 1998 Hospitalization/Surgery: 1998 Back surgery, spinal meningitis age 19 Family History: Mother- HTN Immunizations: N/A Allergies: No known drug allergies Social History: Lives alone in a RV Smoking: No Alcohol Use: yes Recreational Drugs: No Occupation: disabled