Low Back Pain Case Study
Low Back Pain Case Study
Low Back Pain Case Study
PATIENT Kay Salisbury
DOB 03/30/1983
AGE 34 yrs
SEX Female
PRN DP278077
FACILITY
Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 04/05/2017
AGE AT DOS 34 yrs
Not signed
Patient identifying details and demographics
FIRST NAME Kay MIDDLE NAME – LAST NAME Salisbury SSN –
SEX Female DATE OF BIRTH 03/30/1983 DATE OF DEATH – PRN DP278077
ETHNICITY – PREF. LANGUAGE
–
RACE White STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 4994 Shady Range
ADDRESS LINE 2 – CITY Ossawinamakee
Beach STATE MS ZIP CODE 39469
CONTACT BY – EMAIL – HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE – OFFICE EXTENSION
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FAMILY INFORMATION
NEXT OF KIN – RELATION TO PATIENT – PHONE – ADDRESS –
PATIENT’S MOTHER’S MAIDEN NAME
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PATIENT NOTES
Prefers that major diagnoses be discussed with her cardiologist Dr. Seifert
Subjective
The patient is a 34-year-old woman who presents with complaints of back pain. She describes the pain as a “dull ache in my lower back and into my right hip.” She is unable to identify any reason for the onset of pain. The pain does not radiate down legs.
The patient states that the pain has been present for 2 weeks and is progressively getting worse. No urinary or fecal incontinence Low Back Pain Case Study. Patient has not had any imaging studies.
She states that sometimes the pain is worst in the morning and other times it bothers her more during the day. OTC anti-inflammatory medication and ice have provided temporary relief.
Objective
Encounter – Office Visit Date of service: 04/05/17 Patient: Kay S… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 2 4/5/17, 4:31 PM
CLICK HERE TO ORDER Low Back Pain Case Study
Patient’s blood pressure is 116/78. Patient’s HR is 80 bpm and regular. Pain is rated 5/10 while resting and 7/10 while standing and walking Low Back Pain Case Study. Lumbar spine ROM is limited to 50 degrees of flexion. All other lumbar ROM tests are WNL. Physical exam indicates bilateral lumbar muscle spasm and hypertrophy.
Low Back Pain Case Study Assessment
DDX: Lumbar strain with radiculopathy into the right hip and posterior thigh. Possible unilateral vertebral disk herniation or DJD of lumbar spine.
Lumbar strain [847.2]. Lumbar pain [724.2].
Low Back Pain Case Study Plan
Patient is encouraged to continue OTC anti-inflammatory medication b.i.d. Patient will be referred for lumbar and sacroiliac radiography. Radiographic findings will determine the need for follow-up MRI or physical therapy referral. The patient was given a handout on gentle low back stretches and was encouraged to try several gentle yoga positions at home.The patient should return to the clinic in one week.
Free cloud based EHR
Encounter – Office Visit Date of service: 04/05/17 Patient: Kay S… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 2 4/5/17, 4:31 PM
Module 02 Course Project: Clinical Notes
Patient B – Virginia Thompson
If Virginia’s physician had noted any dry or scaly skin during this visit, which medical term might he have used to describe it? (Hint: Think about the word roots you studied this week.)
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In the objective section of this SOAP note, the macules are described as “erythematous.” What color is this word referring to?
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The lesion of concern is located in the anterolateral shoulder. How would you describe the location of this lesion in your own words?
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In which section of this SOAP note (Subjective, Objective, Assessment, Plan) do you find a term that means “pertaining to the acromion and clavicle”?
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What is the definition of a “macule”?
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In this SOAP note, the terms “benign” and “malignant” are used to describe both the skin lesions. Define these terms.
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In the plan section of this SOAP note, the doctor plans to perform a biopsy. Briefly describe this procedure.
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Which word found in this SOAP note means “black tumor”?
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Which word found in this SOAP notes refers to a solid, elevated lesion?
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References for Low Back Pain Case Study
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
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If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa. Select “References” on the left-hand panel and choose “Books” to learn how to properly cite your textbook for this course.
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HCA 459 Week 4 Discussion Question 2
Case 1 Discussion: Allied health program
