Waldorf University Back Pain Episodic Soap Note Case Study i have provided a template and an example of the episodic case study template that you would nee

Waldorf University Back Pain Episodic Soap Note Case Study i have provided a template and an example of the episodic case study template that you would need to use
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?
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 five possible conditions that may be considered in a differential diagnosis for the patient.

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. Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s
own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section
is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the
patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with
age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each
principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the
HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not
completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also
include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of
what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs
intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major
illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous
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and current use), any other pertinent data. Always add some health promo question here – such as
whether they use seat belts all the time or whether they have working smoke detectors in the
house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason
for death of any deceased first degree relatives should be included. Include parents, grandparents,
siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You
should list each system as follows: General: Head: EENT: etc. You should list these in bullet
format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or
edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or
blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
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O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the
differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or
presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive
documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required
for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or
evidenced based guidelines which relates to this case to support your diagnostics and
differentials diagnoses. Be sure to use correct APA 6th edition formatting.
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Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain
S.
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which
began early this morning. The pain is described as “crushing” and is rated nine out of 10 in
terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness
of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief
of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature
cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married
for 39 years
ROS
General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6
systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis,
clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
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P. This section is not required for the assignments in this course (NURS 6512) but will be
required for future courses.
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