SOAP NOTE Name: CL Date: 9/24/19 Time: 1000 Age: 54 Sex: Female ✓ Solved
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SOAP NOTE
Name: CL
Date: 9/24/19
Time: 1000
Age: 54
Sex: Female
SUBJECTIVE
CC: “I’m still having fevers and just feel icky.”
HPI: The patient is a 54-year-old female who is a former paramedic who presents for office visit complaining of generalized weakness, cough and fever that began 4 weeks ago. She was recently diagnosed with Bilateral upper lobe pneumonia at the ER 4 weeks ago. At that time, providers recommended hospitalization, but she refused because she is the primary caregiver for her elderly father. Symptoms have stayed the same since onset. She feels like she isn't moving much air but denies any nausea, vomiting, or diarrhea.
She has seen pulmonary since ER visit and was started on Levaquin and prednisone but then changed to Avelox last week here in the office. The patient describes symptoms associated with fever, chills, and cough along with green sputum production. Symptoms of fever have improved with Tylenol but the fever comes back. Her coughing exacerbates her chest pain. She denies any heart palpitations, diaphoresis, dizziness/syncopal episodes or n/v.
Pertinent medical history includes COPD and hypertension. Patient adds she would like to consider home health to receive IV antibiotics through her chest port.
Medications include:
- Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for fever
- Abilify 20mg daily
- Baclofen 10mg daily
- Clonazepam 1mg QID PRN
- Fluoxetine 40mg daily
- Lasix 40mg daily
- Gabapentin 600mg daily
- Klor-Con M10 meq daily
- Lisinopril 40mg daily
- Losartan/HCTZ 100/25 daily
- Metoprolol tartrate 100mg TID PM
PMH Allergies: Codeine
Medication Intolerances: Denies
Chronic Illnesses/Major traumas: Von Willebrand disorder, hypertension, anxiety, bipolar disorder, Vitamin D deficiency, COPD, PVD, insomnia.
Hospitalizations/Surgeries: Appendectomy (2001)
Family History:
- Mother-(deceased): COPD, Hypertension, MI, hypothyroidism
- Father-(alive): dementia, anxiety/depression, CHF, CAD, HTN
Social History:
General: Born and raised in Great Falls, SC.
Marital Status: Married
Living Situation: Her father lives in the home with the patient’s family.
Children: 17-year-old boy and 12-year-old girl.
Occupation: Teacher at local elementary school.
Leisure Patterns: Patient states she reads a book when she gets a chance.
Social habits: Denies smoking or alcohol consumption. Does not exercise.
Spirituality: Christian
Nutrition: Balanced diet. She mostly cooks at home and rarely eats fast food.
Sleep Patterns: States that she usually gets about 5 hours.
ROS
General: Reports weakness, fatigue, or fever. Denies headache, head injury, dizziness, or lightheadedness.
Cardiovascular: Denies any troubles with her heart, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema.
Skin: Denies rashes, lumps, sores, itching, and changes in color. Denies changes in her nails or hair. Denies changes in size or color of moles.
Respiratory: Reports cough, yellow-greenish sputum, wheezing, and shortness of breath that worsens at night.
Eyes: Denies any changes in her vision. Does not use glasses. Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, or cataracts.
Gastrointestinal: Denies trouble swallowing, heartburn, changes in appetite, or nausea. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance, or excessive belching or passing gas.
Ears: States she doesn’t have any hearing problems. Denies tinnitus, vertigo, earaches, infection, or discharge. Denies use of hearing aids.
Genitourinary/Gynecological: Goes to the bathroom 4 or 5 times a day. Denies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.
Menarche at age 13. States she gets her period approximately every 28 days and it lasts about 5 days. Flow heavier on the first 2 days. Denies bleeding between periods. LMP: September 4th. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G1 P1, spontaneous vaginal delivery at 39 weeks. Denies any complications with her pregnancy. Denies use of birth control methods.
Not sexually active at the moment. Has had one partner in the past 5 years. Denies exposure to HIV infection or STDs.
Nose/Mouth/Throat: Patient states she gets occasional allergies and colds that cause her to have stuffiness and discharge. Denies hay fever, nose bleeding, or sinus trouble. Throat: States her teeth are yellow and sometimes her gums would bleed. Denies use of dentures. Last dental examination was 2 years ago (Oct/15). Denies sore tongue, frequent sore throats, or hoarseness. Denies having dry mouth or excessive thirst.
Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.
Musculoskeletal: Denies muscle weakness, paresthesia, loss of sensations, no severe or progressive neurological deficit in the lower extremity. No history of cancer, or risk factors for spinal infection (no IV drug abuse, UTI, immune suppression). Patient reports feeling lower back pain that started yesterday while at work that is worse in the right lumbosacral area. Pain radiates to her right buttock. Patient states it hurts to stand up or find a comfortable position. States her back hurts even at rest, but pain gets worse when she moves. Pain worsens after bending or lifting. Denies other muscle or joint pain, stiffness, arthritis, or history of gout. Denies fever, chills, rash, anorexia, weight loss, or weakness.
Breast: Denies lumps, pain, discomfort, or nipple discharge.
Neurological: Denies changes in mood, attention, or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness, or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.
Heme/Lymph/Endo: Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria, or changes in shoe size. Denies weight changes or fever.
Peripheral Vascular: Patient states she has a few spider veins that look like bruises, she got them during the pregnancy. Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs, or feet. Patient states there have not been any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness.
Psychiatric: Denies nervousness, tension, mood changes, depression, or memory changes.
OBJECTIVE
Weight: 120lbs
BMI: 20
Temp: 98°F
BP: 114/74
Height: 67”
Pulse: 89
Resp: 20
General Appearance: Skin warm and dry without discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned without signs of acute distress.
Skin: Skin is warm, pink, and supple, no lesions noted.
HEENT: Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows without difficulty, no erythema; Neck: thyroid non-palpable, no carotid bruits.
Cardiovascular: Carotid upstrokes are brisk, without bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+, brisk, and symmetric.
Respiratory: Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or ronchi.
Gastrointestinal: Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.
Breast: Deferred
Genitourinary: Deferred
Musculoskeletal: No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees, and ankles. Gait/Posture: Flexed forward at 15º, walked slowly with a wide based stance, and grimaced with movement. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis; unable to extend or rotate. Lateral movement: bilaterally to 20º. All attempts at ROM produced pain. Right paravertebral muscle spasm noted in lumbar area. Straight leg raise (SLR) negative, Patrick test negative, crossed SLR negative. No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.
Neurological: Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2+ and symmetric with plantar reflexes downgoing.
Psychiatric: Alert, relaxed, and cooperative. Thought process is coherent. Oriented to person, place, and time.
Lab Tests: None ordered today.
Special Tests: None ordered today.
Diagnosis
Diagnosis: 1. Acute lumbosacral strain (M54.5) Differentials: 1. Acute lumbosacral pain (M54.5): Minimal discomfort initially followed by increased pain and stiffness 12-36 hrs later, SLR, crossed SLR, heel and toe walking were intact. No muscular weakness or loss of sensation. DTRs were equal and not depressed. Babinski negative. Spasm noted in paravertebral muscles.
2. Herniated lumbar disc (M51.2): Pain in buttocks. 3. Sciatica (M54.3): Pain in back/buttocks. 4. Possible vertebral Fx (S32.009A): Low back pain.
Plan/Therapeutics
Plan: Diagnostic: No tests needed at this time
Therapeutic:
- Pharmacological: D/C OTC Tylenol. Start Ibuprofen 600mg 1 po q8h x 7 days then PRN for pain. Robaxin 500mg 1 po QAM, 2 po QHS x 2 weeks then 1 po Q8H PRN for back pain.
- Non-pharmacological: Local application of ice may help initially to decrease pain, apply cold pack for 20 minutes q2-3 hours while awake. After 2-3 days, either heat or ice may be applied. No bed rest indicated. Take 3-7 days off work (her job would increase stress on her back), or perform other duties until the symptoms abate.
Patient Education:
- Avoid jerky, hurried movements when lifting.
- Lift with legs by straddling the load; bend knees to pick up load; keep back straight (do not bend back).
- Keep objects close to the body at navel level when lifting.
- Avoid twisting, bending, reaching while lifting.
- Avoid prolonged sitting.
- Change positions often while sitting.
- A soft support belt for the back, armrests to support some body weight, a slight reclining chair may make sitting more comfortable.
- Firm mattress/bed board, lying supine with hips and knees flexed on pillows is beneficial when sleeping.
- May return to work in 4-8 days.
- As soon as she returns to regular activities (in 2 weeks), aerobic conditioning exercises such as walking, swimming, stationary biking, or even light jogging may be recommended to avoid debilitation.
Referral: None
Follow-Up: Come back if the pain does not improve by 50% in 24-48 hrs. Return to the office in 7-10 days. Return sooner if neurological symptoms worsen or bowel/bladder dysfunction occurs.
Evaluation of Patient Encounter: I was able to assess the patient independently and then later present the case to my preceptor by providing her with the pertinent positive on the ROS and on the physical exam findings. I participated in the Dx selection and in the treatment plan.
Weaknesses: I must work on managing my time. It took me almost 45 minutes to work on this case.
Strengths: I have improved my physical exam skills, I feel confident and comfortable interacting with patients on my own.
Reflection: I feel like I am improving with collecting enough information and with performing focused physical exams. I feel like everything is starting to fall into place.
References
- Bickley, L. (2007). Bates’ Guide to Physical Examination & History Taking (9th Edition), Lippincott, Williams and Wilkins Publishers
- National Guideline Clearinghouse. (2008). Management of Acute Low Back Pain.
- Uphold, C., & Graham, M. Clinical Guidelines in Family Practice (4th ed.). Gainesville, FL: Barmarrae Books Inc.
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