PRAC 6568 Week 3 Assignment 1; Focused SOAP Note

FOCUSED SOAP NOTE 3219450287937 Master of Science in Nursing, Walden University PRAC 6568C: Synthesis in Advanced Nursing Practice of Patients in Family Care Settings Dr. Fuller September 14, 2023 Focused SOAP Note Patient Information: JS, 36, Male, White S. CC: "Back pain" HPI: JS is a 33 YO white male who presents for right lower back pain. Patient reports the pain in back started this morning around 0700 when he went to get out of bed. The pain is to the lower right side of his back and radiates down the back of the leg to his knee. The pain is described as constant and "stinging". Patient has a slight limp with ambulation. Denies numbness or tingling. No changes in bowel or bladder pattern. Hx of sciatica and treatment for the condition but says it was about 10 years ago. Pain is worse with sitting. Says he feels better when he lays down but must have his right knee bent for comfort. Patient did take 500 mg of Naproxen prior to arrival. Denies any relief from medication. No ice or heat attempted. Severity: 8/10 pain scale Current Medications: Naproxen 500mg by mouth prn back pain Allergies: Denies medication, latex, food, and environmental allergies PMHx: Tdap -2019 Childhood immunizations utd PSx: Denies Soc & Substance Hx: Patient is married with 2 children. He is a project manager for an I.T. company. He works from home and does a lot of sitting at the computer during the day. Denies any current of previous history of tobacco use. Denies marijuana or illicit drug use. Drinks an occasional 1-2 beers on the weekends with friends while watching football. Per patient " Go Steelers". Lives in a single-family home. Family has a golden retriever named " Jax". He does wear his seatbelt. Home has working carbon monoxide and smoke detectors. No guns in the home. His parents live in South Carolina, but his in-laws are 20 minutes away and are supportive of the family. Fam Hx: Identify illnesses with possible genetic predisposition, and 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. Surgical Hx: Denies hx of prior surgical procedures Mental Hx: Denies hx of depression or anxiety Violence Hx: Denies concern for violence Reproductive Hx: Denies hx of STI's. Sexually active with his wife ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue SKIN: No lesions, eczema, rash, or itching CARDIOVASCULAR: No chest pain/pressure, no palpitations, no edema RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No abdominal pain, nausea, vomiting, or diarrhea GENITOURINARY: No flank pain. Denies dysuria NEUROLOGICAL: No tingling or numbness, tingling, or loss of sensation. No loss of bowel or bladder function, no loss of balance/coordination MUSCULOSKELETAL: Right lower back pain. Limp with ambulation. Denies joint pain or stiffness O. Physical exam: Vital signs: BP 124/78 L arm sitting. RR 18. 02 98% RA. HR 80. Temp 97.8F Oral. HT 6’2” WT