MUSCULOSKELETAL TINA JONES SOAP

S.O.A.P. Note Template CASE ID# Tina Jones Musculoskeletal Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) What brought you here today (eg. headache) “I have a lot of pain in my lower back.” History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Patient is a 28-year-old African American woman who presented to the clinic complaining of back pain that began 3 days ago. She states she “tweaked it” while lifting a heavy box. She states that lifted several boxes to help her friend who was moving, she does not know the weight of the box that caused her pain. She states the pain is in her low back and bilateral buttock. She describes the pain as constant aching with stiffness but does not radiate. She states the pain is at its worse while sitting, which rates a 7/10. The pain decreases with rest and lying flat on her back, which she rates approximately 3-4/10. The pain has not changed over the past three days She has treated the pain with 2 over the counter ibuprofen tablets every 5-6 hours. She states the ibuprofen can decrease her pain to 2/0. Her current pain is a 5/10. She denies numbness, tingling, muscle weakness, bowel or bladder incontinence. She denies neck pain. She denies any history of back of neck pain. She denies history of trauma or accidents. She reports that pain is interfering with her sleep and activities of daily living. Location Duration Character Aggravating/associate d factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, Adult illness: diabetes, asthma Childhood illness: asthma at 2.5 years old Immunizations: up to date, received annual flu shot Family History Include Parents, siblings; grandparents if applicable/known, cause of death, age, Mother: Alive 59 y.o., High blood pressure, high cholesterol Father: Deceased at 58 due to car accident Type II Diabetes, high blood pressure, high cholesterol Paternal grandmother: Alive 84 y.o., High blood pressure, high cholesterol Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, Education: Current Student Marital Status: Single Occupation: supervisor at Mid-American Copy and Ship Religion: Christian Social History: Denies drug use, non-smoker, denies vaping, social drinking- no more than 4 drinks a month This study source was downloaded by from CourseH on :04:35 GMT -05:00 Review of Systems General: Denies weight loss, fatigue, chills, fever, and night sweats Hair, Skin, & Nails: Denies rash, skin color changes, masses, hair loss, nail changes Head: Denies headache or history of head trauma Neck: Denies stiffness, tenderness, or pain. Eyes: Denies vision changes, light sensitivity, flashes of light, eye pain, diplopia, or floaters Ears: Denies ear pain, hearing loss, discharge Nose: Denies discharge, change is smell, or pain Mouth & Throat: Denies change in taste, sore throat, bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. Cardiovascular: Denies chest pain or palpitations. Respiratory: Denies coughing, dysphagia, difficulty breathing. Breasts: Not assessed Gastrointestinal: Denies abdominal pain, decreased appetite, diarrhea, constipation, flatus, nausea, vomiting, or bloating. Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. Reports decreased range of motion of back. Reports pain in her lower back has impacted sleeping and sitting. Denies numbness, tingling, radiation, or bowel/bladder dysfunction. Denies previous musculoskeletal injuries or fractures. Peripheral: Not addressed Neurological: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, or seizures Psychiatric: Reports occasional feelings of anxiety and stress. This study source was downloaded by from CourseH on :04:35 GMT -05:00