NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week 8: SOAP NOTE- Assessing Musculoskeletal Pain
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format.
Please POST a SOAP Episodic/FOCUS note ONLY!
Refer to the Episodic/Focused SOAP Template I provided below
Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least fivepossible conditions that may be considered in a differential diagnosis for the patient.
Utilize at least 3 scholarly, peer reviewed sources.
Utilize SafeAssign Drafts to obtain originality report before final submission.
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Case Study: Back Pain
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
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Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.
Medications:
Norvasc 10mg daily
Combivent 2 puffs every 6 hours as needed
Advair 500/50 daily
Singulair 10mg daily
Over the counter Tylenol 325mg as needed
Over the counter Benefiber
Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Cipro-headache
Past Medical History (PMH):
Asthma
Hypertension
Osteopenia
Allergic rhinitis
Prostate Cancer
Past Surgical History (PSH):
Cholecystectomy 1994
Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.
He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.
HEENT: no changes in vision or hearing; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or compression..
Breasts:. Denies history of lesions, masses or rashes.
Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.
CV: denies chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.
GI: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.
Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.
Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.
Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound
Genital/Rectal: pt declined for this exam
Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Diagnosis (DDx):
Asthmatic exacerbation, moderate
Pulmonary Embolism
Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
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Week 8: Assessing Musculoskeletal Pain
Assessing Musculoskeletal Pain
Patient Initials: S.K Age: 42 years old Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “Pain in my lower back for the past one month”
History of Present Illness (HPI): S.K is a 42-year-old Caucasian male patient who reported to the clinic with pain in his lower back that had lasted for about a month. he reports that the pain radiates to his left leg sometimes. The patient reports that the pain is worse when working, and is less disturbing when resting. He has been taking ibuprofen which he claims to provide minimal relief.
Location: lower back
Onset: about a month ago
Character: constant and sharp pain radiating to the left leg
Associated signs and symptoms: None
Timing: When handling strenuous work
Exacerbating/ relieving factors: Any movement worsens the pain. Resting and Ibuprofen provides minimal relief.
Severity: 7/10 on a pain scale
Medications:
Ibuprofen 800mg PO PRN for the back pain
Allergies:
No known environmental, food, or drug allergies.
Past Medical History (PMH):
Denies any history of a serious medical diagnosis
Past Surgical History (PSH):
Denies ever undergoing any surgical procedure in the past.
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
Married with 3 children
Works in a book store downtown.
Has never smoked tobacco or marijuana.
Confirms taking 2 to 3 beers occasionally when with friends.
Immunization History:
Flu shot 17/2/2022
Covid Vaccine #1 2/1/2021 #2 3/1/2021 Moderna
All other immunization up to date
Significant Family History:
Mother- with HTN and DM
Father- with gout and kidney disease
Maternal grandmother- with kidney disease
Maternal grandfather- died from a stroke
Paternal grandmother- with COPD
Paternal grandfather with CAD, HTN, and COPD.
He has 2 daughters and one son who are all healthy with no significant health complications.
Lifestyle:
The patient works in a bookstore downtown. He is happily married to a junior school teacher with 3 children. They live on the outskirts of the city in a 3 bedroom apartment in a safe neighborhood. The means of transport is good, with easily accessible fresh water and healthcare services.
He tried as much as possible to eat a healthy diet together with his family. He walks the dog every evening for about a kilometer as a form of exercise. Uses seat belts when in the car, with safety equipment such as a first-aid kit available in their home. He is a strong church member and socializes with his friends mostly over the weekend.
Review of Systems:
General: No recent changes in body weight. Complains of pain in his lower back. Denies constipation, fatigue, chills, fever, or generalized body weakness.
HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.
Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.
CV: Denies chest pain, edema, PND, orthopnea, syncope, or palpitations. Dyspnea on exertion
GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.
GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.
MS: Reports lower back pain which sometimes radiates to the left leg. He rates the pain at 7/10 on a pain scale. The severity of the pain however worsens when walking or turning when sleeping. The patient confirms that the pain has lasted for about a month, making it harder to exhibit a full range of movement on the left leg. No numbness, swelling, or redness was reported.
Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.
Neuro: Reports back pain that radiates to the left leg. Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.
Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.
Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.
Allergic/Immunologic: Denies hay fever, urticaria, persistent infections, or HIV exposure.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 140/96, left arm, sitting, regular cuff; P 88 and regular; T 98.9 Orally; RR 18; non-labored; Wt: 215 lbs; Ht: 5’8; BMI 32.69
General: The patient appears healthy, and well oriented in person, place, and time. Seems to be uncomfortable and in moderate pain.
HEENT: External ears normal, with no deformities or lesions. External nose normal with no deformities or lesions. Bilaterally clear canals. Intact tympanic membrane with good movement and no fluid. Grossly intact bilateral hearing. Normal nasal mucosa, septum and turbinates. Complete and good hygienic dentation.
Neck: Supple with no masses. Trachea midline, No thyroid nodules, tenderness, or masses.
Chest/Lungs: Bilaterally clear to auscultation. Tactile fremitus normal. No signs of egophony. Normal respiratory effort displayed with no use of accessory muscles.
Heart/Peripheral Vascular: S1, and S2, note. Normal cardiac rhythm with no murmur, gallop, or rubs.
ABD: Suprapubic surgical scar, obese, non-tender, soft, and non-distended abdomen with no masses.
Genital/Rectal: The patient did not consent to this examination.
Musculoskeletal: Low back pain noted, radiating to the left lower leg. No evidence of trauma affecting the area was noted. Tenderness increases with extension, flexion, and twisting. Limited ROM in the left leg.
Neuro: Cranial nerves: II – XII grossly intact; 2+, symmetric, reflexes.
Diagnostics/Lab Tests and Results:
CBC – To evaluate for spinal infections
CSF analysis- For suspected spinal infection or inflammatory etiologies
X-ray of the spine- for flexion-extension views to identify spondylolisthesis and spinal instability.
MRI of the spine- to assess for suspected myelopathy or radiculopathy.
Electromyography (EMG)- to confirm compressions caused by spinal stenosis or herniated disks (Urits et al., 2019).
Assessment:
Differential Diagnosis (DDx):
Sciatica: This condition is characterized by pain that normally radiates along the sciatic nerve path, which branches from the patient’s lower back through to the buttocks and hip, and down to each leg (Kim et al., 2018). However, sciatica normally affects one side of the body. The patient in the provided case study presents with lower back pain that radiates to the left leg, which is a great indication of sciatica as the primary diagnosis.
Lumbar disc herniation: LDH is characterized by lower back pain and is common among adults between the age of 35 and 50 years. It normally results from changes in the structure of the lower lumbar spinal disk between the 4th and 5th vertebrae and between the 5th lumbar vertebra and the 1st sacral vertebra (Benzakour et al, 2019). Most patients normally present with symptoms such as lower back pain, radicular pain, limited trunk flexion, and weakness at the lumbosacral nerve roots distribution. The patient in the provided case study displayed lower back pain, however, an MRI of the spinal column is needed to confirm this diagnosis.
Lumbar spinal stenosis: LSS is associated with narrowing of the spinal canal located in the lower back resulting in pain. Stenosis causes pressure on the patient’s spinal cord or nerves connecting the spinal column and the muscles (Deer et al., 2019). As such patients will present with lower back pain just like the one in the provided case study. However physical examination is required to assess for the presence of loss of sensation, abnormal reflexes, and weakness to confirm this diagnosis.
Lumbar muscle strain: LMS is described as an injury to the lower back characterized by mild to moderate lower back pain. The injury can lead to damage to the muscle or tendons causing spasms and soreness (Urits et al., 2019). An x-ray is however needed to confirm the impact of the injury on the tendon or muscle to confirm the diagnosis
Ankylosing spondylitis: This is an inflammatory disorder, that can lead to some of the spinal bones fusing over time. It is characterized by pain in the joints and the back (Ogdie et al., 2019). Symptoms normally appear early in life, including reduced flexion of the spine. The patient only presented with back pain which radiates to the left leg with no joint pain or reduced flexion of the spine.
Primary Diagnoses:
1.) Sciatica
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
References
Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International orthopedics, 43(4), 841-851. https://doi.org/10.1007/s00264-018-4247-6
Deer, T. R., Grider, J. S., Pope, J. E., Falowski, S., Lamer, T. J., Calodney, A., … & Mekhail, N. (2019). The MIST guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Practice, 19(3), 250-274. https://doi.org/10.1111/papr.12744
Kim, J. H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., … & Verhagen, A. P. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropractic & manual therapies, 26(1), 1-14. https://doi.org/10.1186/s12998-018-0207-x
Ogdie, A., Benjamin Nowell, W., Reynolds, R., Gavigan, K., Venkatachalam, S., de la Cruz, M., … & Park, Y. (2019). Real-world patient experience on the path to diagnosis of ankylosing spondylitis. Rheumatology and Therapy, 6(2), 255-267. https://doi.org/10.1007/s40744-019-0153-7
Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D. (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current pain and headache reports, 23(3), 1-10. https://doi.org/10.1007/s11916-019-0757-1