Roszina Tekola Holmes 4:58amJul 19 at 4:58am Assessing Musculoskeletal Pain Epi

Roszina Tekola Holmes 4:58amJul 19 at 4:58am
Assessing Musculoskeletal Pain
Episodic/Focused SOAP Note Template
Patient Information:
MFC, 42, Male
S.
CC: The patient is experiencing lower back ache for two months. The pain at times radiates to his left leg
HPI: MFC, a 42-year-old white male patient, has complained of low back discomfort since he showed up at the clinic today. The pain has been on since the last two months. His movement was restricted by the soreness, which sometimes spread to his left leg, interfered with his everyday routines, and even kept him from going to work.
Current Medications:
Lisinopril 10 mg once a day
Ibuprofen 800 mg every six hours on demand
Allergies: Pork Meat
PMHx: Diabetes diagnosis three years ago.
Soc Hx: MFC is married and is sexually active with wife. He has three children—two of whom are now in college and are no longer living at home
Fam Hx: Family history reveals that the mother has a history of hypertension and diabetes mellitus, whereas the father is free of such a condition.
ROS:
GENERAL: Patient is worn out but has no fever, chills, or recent weight change.
HEENT: There is no throat swelling at this time. The patient adamantly maintains that there is no throat irritation.
SKIN: The skin is intact, warm to the touch, and seems damp.
CARDIOVASCULAR: The patient’s S1, S2; no S3 or S4 is acceptable, and the heart rate is normal.
RESPIRATORY: The patient disputes having difficulty breathing and coughing.
GASTROINTESTINAL: There were no signs of anorexia, nausea, vomiting, or diarrhoea. There was no stomach pain and no blood.
GENITOURINARY: No overt problems connected to the frequency of urination.
NEUROLOGICAL: The patient had no syncopal or dizzy episodes, paresthesias, or headaches.
MUSCULOSKELETAL: The absence of back pain, joint pain, and stiffness.
HEMATOLOGIC: No signs of bleeding, bruising, or anaemia.
LYMPHATICS: No enlarged lymph nodes are seen. There was no prior history of splenectomy.
PSYCHIATRIC: The patient seems to know his surroundings and where he is.
ENDOCRINOLOGIC: There have not been any reports of overactive perspiration or extreme sensitivity to cold or heat. Neither polydipsia nor polyuria exist.
ALLERGIES: Pork meat.
O.
Physical exam:
I will look at the patient’s general appearance throughout the physical examination, paying close attention to the symmetry of the patient’s posture and motions. I will assess the arms or legs muscles for strength and nerve function.
Diagnostic results: The test to be performed include;
A lumbar spine X-ray
A cervical and lumbar vertebrae CT scan
A.
Differential Diagnoses
Muscle strain: A muscle strain is a muscular injury that develops due to excessive pressure on the muscle. Uncomfort is a symptom present in the patient and accompanied by muscle tension.
Osteoporosis. Another disorder that might be linked to lower mineralized bone mass. Compression fractures of the vertebral bodies, often in the thoracic area, might result from this. Like a patient whose pain extends down their left leg, back pain is often chronic and difficult to pinpoint (Clynes et al., 2020).
Herniated lumbar disc. The third potential issue is a herniated disc in the lower back. He claims that a herniated disc is an issue with one of the discs between the vertebrae that make up the spine, resulting in pain in the arms or legs. Additionally, the cervical spine may be affected. The diagnosis is often made using an MRI, X-rays, and a CT scan of the lumbar spine (Elsharkawy, Hagemann & Klassen, 2019).
Sciatica: Like the patient, this ailment is characterized by symptoms like leg discomfort or lower back pain. Leg issues might also result from sciatica.
Ankylosing Spondylitis: The last ailment that might manifest as symptoms like back discomfort (Ebrahimiadib et al., 2021)
References
Clynes, M. A., Harvey, N. C., Curtis, E. M., Fuggle, N. R., Dennison, E. M., & Cooper, C. (2020). The epidemiology of osteoporosis. British medical bulletin, 133(1), 105-117. doi: 10.1093/bmb/ldaa005
Ebrahimiadib, N., Berijani, S., Ghahari, M., & Pahlaviani, F. G. (2021). Ankylosing spondylitis. Journal of Ophthalmic & Vision Research, 16(3), 462. doi: 10.18502/jovr.v16i3.9440
Elsharkawy, A. E., Hagemann, A., & Klassen, P. D. (2019). Posterior epidural migration of herniated lumbar disc fragment: a literature review. Neurosurgical review, 42(4), 811-823. https://doi.org/10.1007/s10143-018-01065-1