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NURS 6512 Discussion Episodic/Focused SOAP Note

NURS 6512 Discussion Episodic/Focused SOAP Note

NURS 6512 Discussion Episodic/Focused SOAP Note

Patient Information:

A.S Age 42-year-old African American male
S.
CC Lower back pain for the last one month
HPI: The patient is a 42-year-old male who came to the hospital with complaints of lower back pain for the last one month. The patient reported that the pain at times radiates to his left leg. The patient also reported that the pain has been increasing if he sits for a long time. The pain is relived when he stands. The patient denies any fever or pain. He pains rating at the time of assessment was reported to be 8/10.
Current Medications: The patient reported to be using acetaminophen 1 gram, TDS for the last one week, which has not been effective in relieving the pain.
Allergies: The patient denied any history of food, drug, or environmental allergy.
PMHx: The patient was admitted to the hospital in 2015 due to pneumonia. He also has a history of admission in 2010 due to anemia. The patient does not have any history of surgery. He also does not have any history of blood transfusion.

Soc Hx: The patient is married. He works as a librarian in a community library. The patient does not smoke or uses alcohol. He engages in regular physical activity, which has been limited by his condition. He reported to live in a healthy environment with enhanced access to healthy diets. He has three children who are currently in college.
Fam Hx: The patient denied any history of chronic illnesses in his family. Both of his parents are alive, without any chronic illnesses.
ROS:
GENERAL: The patient was dressed appropriately for the occasion. There was no evidence of weight loss. The patient however had slowed movements due to lower back pain. The patient denied fever, chills, fatigue or weakness.
HEENT: Eyes: The patient denied visual loss, blurred vision, double vision or eye drainage. Ears, Nose, Throat: The patient denied hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: The patient denied rash or itching.
CARDIOVASCULAR: The patient denied chest pain, chest pressure or chest discomfort. palpitations or edema.
RESPIRATORY: The patient denied shortness of breath, cough or sputum.
GASTROINTESTINAL: The patient denied anorexia, nausea, vomiting or diarrhea. He also denied abdominal pain or blood.
GENITOURINARY: The patient denied burning on urination increased urinary frequency or changes in urine color and smell.
NEUROLOGICAL: The patient denied headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. He also denied any changes in bowel or bladder control.
MUSCULOSKELETAL: The patient complained of lower back pain that radiates to the right leg. The self-reported pain rating of the client was 8/10. The client reported that the pain increases with prolonged sitting or turning in bed. The patient also reported the pain to have affected his ability to walk, as he is forced to walk slowly to minimize pain. The patient reported that the pain has persisted for the last one month. The pain radiates to the left leg when he walks. He denied any numbness. The pain is relieved when he stands. Acetaminophen has been effective in the past in relieving it. However, he feels that it is not helping, as he has to depend on it to minimize pain.
HEMATOLOGIC: The patient denied anemia, bleeding or bruising.
LYMPHATICS: The patient denied enlarged nodes.
PSYCHIATRIC: The patient denied any history of depression or anxiety.
ENDOCRINOLOGIC: The patient denied reports of sweating, cold or heat intolerance. He also denied polyuria or polydipsia.
ALLERGIES: The patient denied any history of food, drug or environmental allergens.
O.

Physical exam:

Vitals: BP 123/76 P 70, R 20, T 98.7 F, SAT 98%, Wt. 56 kg, Ht. 5’9, pain 8/10
General: The patient is a 42-year-old, who appears well-dressed for the occasion. He does not have any evidence of weight loss. His walking pace is reduced due to lower back pain. He is oriented, alert, and cooperative. He has slight limp due to lower back pain.
HEENT: The head is normocephalic with normal distribution of hair. There is the absence of facial tenderness, with pink conjunctiva and white sclera and absence of jaundice. The pupils react to light. There is absence of eyes and ear drainage. There are absence of erythema, lesions or exudates on the pharynx and nasopharynx. The mucus membranes are moist with absence of dentures.
Neck: There is the absence of swollen lymph nodes, neck rigidity, and swelling.
Chest/Lungs: lungs are clear, with equal symmetry on respiration. There is absence of wheezing, stridor, or rhonchi. There is the absence of palpitations and abnormal heart sounds.
Gastrointestinal: There is the absence of abdominal swelling, scars, or evident blood vessels. There is also the absence of organomegaly and presence of normal bowel movements.
Genitourinary: The patient denied assessment of the genitourinary system.
Neurological: There is absence of numbness, paralysis, muscle weakness, loss of body balance, and urinary or bowel incontinence.
Musculoskeletal: Lower back pain reported. Difficulty in movement on a wide range of motions noted. Absence of rigidity of the lower limbs. Liming on motion noted with reduced pace in walking. Patellar reflexes present with self-reported pain rated at 8/10. There is the absence of joint or muscle rigidity.

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NURS 6512 Discussion Episodic/Focused SOAP Note
NURS 6512 Discussion Episodic/Focused SOAP Note

Hematology: Absence of bleeding gums

Lymphatic: Absence of lymphadenopathy
Psychiatric: The patient is alert and oriented to place, self, others, and time. His judgment is intact. He denies any history of suicidal thoughts, plans, and attempts, delusions, illusions, and hallucinations.
Endocrinology: Absence of polyuria, polydipsia and oliguria
Diagnostic results: The first diagnostic investigation that is appropriate for the patient in the case study is x-ray. X-ray of the cervical region should be performed to determine if the patient has bone misalignment, arthritis or fractures. MRI and CT scans can also be performed to determine whether there is nerve involvement and internal organs. The scans also enable the determination of issues such as disk herniation and problems with blood vessels. Electromyography may also be indicated to determine the electrical impulses that nerves produce and muscle response (Jensen et al., 2019). The test guides in the diagnosis of nerve compression due to spinal stenosis or disk herniation.
A.

Differential Diagnoses

Sciatica: The primary diagnosis for the patient in the case study is sciatica. Sciatica is a pain that develops from dick herniation or spinal stenosis that cause nerve compression. Patients experience pain at the path of the sciatic nerve that is affected to the lower limbs. The compression of the nerve results in nerve inflammation, pain, and at times numbness of the affected limb (Jensen et al., 2019). Patients with sciatic develop symptoms that include pain radiating to the affected limb, discomfort in sitting, and worsening of pain with prolonged activities such as sitting and sneezing (Maslak et al., 2020). The patient in the case study experiences the above symptoms. As a result, sciatica is the primary diagnosis that should be considered in the development of the treatment plan.
Spinal claudication: Spinal claudication is the secondary diagnosis that should be considered for this patient. Spinal claudication arises from the marked narrowing of the spinal canal. The narrowing results in pressure build up on the cauda equina. The resulting symptoms that patients experience include legs and lower back discomfort when one moves or engages in exercises. Patients also experience pain, weakness, tingling, and numbness of the affected limbs. There is also the feeling of heaviness of the affected limbs (Barbaro & Midgley, 2021). The patient in the case study does not experience some of the above symptoms, hence, making spinal claudication a secondary diagnosis.

Peripheral neuropathy: Peripheral neuropathy is the other secondary diagnosis that should be considered for the patient. Peripheral neuropathy arises from the systemic diseases such as metabolic syndrome, diabetes, and genetic disorders including Charcot-Marie-Tooth disease (Hicks & Selvin, 2019). Patients with infections such as leprosy, HIV and nutritional deficiencies are also predisposed to peripheral neuropathy. Patients often experience symptoms such as burning pain, tingling and numbness, and muscle weakness in the affected limb (Iqbal et al., 2018). The patient in the case study does not have any history of systemic disease, infection or nutritional deficiencies, hence, the least likely cause of the health problem.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Barbaro, K., & Midgley, J. (2021). Priapism, a symptom of claudication of the cauda equina in spinal stenosis. Musculoskeletal Science and Practice, 52, 102337. https://doi.org/10.1016/j.msksp.2021.102337
Hicks, C. W., & Selvin, E. (2019). Epidemiology of Peripheral Neuropathy and Lower Extremity Disease in Diabetes. Current Diabetes Reports, 19(10), 86. https://doi.org/10.1007/s11892-019-1212-8
Iqbal, Z., Azmi, S., Yadav, R., Ferdousi, M., Kumar, M., Cuthbertson, D. J., Lim, J., Malik, R. A., & Alam, U. (2018). Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy. Clinical Therapeutics, 40(6), 828–849. https://doi.org/10.1016/j.clinthera.2018.04.001
Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ, 367, l6273. https://doi.org/10.1136/bmj.l6273
Maslak, J. P., Jenkins, T. J., Weiner, J. A., Kannan, A. S., Patoli, D. M., McCarthy, M. H., Hsu, W. K., & Patel, A. A. (2020). Burden of Sciatica on US Medicare Recipients. JAAOS – Journal of the American Academy of Orthopaedic Surgeons, 28(10), e433. https://doi.org/10.5435/JAAOS-D-19-00174

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