SOAP Note of Neurologic, musculoskeletal, and cardiopulmonary week 3

Patient Information: Initials Mrs. A. F Age 29 Sex Female Races Caucasian Insurance EHP S. Chief Complaint (CC): A.F. is a 29-year-old Caucasian female presented to the clinic with the chief complaints of a headache, back pain, and cough. HPI: A. F. is a 29 years old Caucasian female presented to the clinic to further evaluate a headache that is been going on and off for about a month with episode since yesterday, back pain for about 1 week and cough for past 2 days. Headache: A. F. reported about 3 episodes of an intermittent headache that usually lasted 2 to 3 days within the last month. She reported continuous throbbing pain in the frontotemporal region since yesterday evening. Before a headache started, she reported not feeling well, tired, irritable, and neck stiffness throughout the day. She thought she had a busy day at work and was really tired so took the hot shower and went to bed early. She woke up the middle of the night feeling sick, dizzy, and weak followed by a worse headache. She reported those symptoms were very similar to one she had 2 weeks ago. She explained her headache as “pounding” achiness that feels like “my head is going to explode” at the frontal and temporal region and rates 10/10 in the scale of 0-10. It gets worse with activity, light, and loud noise and had some relief with laying down, eye shield, and over-the-counter medication such as Advil. Back Pain: A.F. complains of 1 week of acute onset of lower back pain. She is an RN working in the rehabilitation unit. She requires a lot of lifting, pulling, and pushing at her job. She reported pulling a patient weight more than 200lb up in the chair. She felt her lower back was overstretched and felt like something popped followed by acute onset of pain. She reported an incident at the occupational health center. She was instructed to refrain from activity, rest for a week, heat pack, diclofenac gel, and take over-the-counter NSAIDs PRN for pain. She now presented with continuous sharp pain in the lower back that radiates to bilateral lower legs rates 5-7 in the scale of 0-10, numbness and decreased sensation on legs, and difficulty with activity. She denies changes in bladder or bowel function and tingling. She reported that the pain is worse with activity and change in position and relieved with rest, heat, and over-the-counter NSAIDs. Cough: A. F. also reported cold like symptoms about 10 days ago which is resolved, but has a nagging cough for past 2 days. She explained it as a dry cough that gets worse at night and better during the daytime. She denies a sore throat, runny nose, congestion, or fever. Exposure to cold makes it worse and fl