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Answered step-by-step
Asked by MateApeMaster380
SOAP needed w/ 3 three differential diagnoses and resourcesÂ
INFO
37 y/o AAF comes to the office for a routine three-month follow-up.  reporting increasing lower back pain for the past few weeks  and a nodule on the right wrist (noticed 3 days ago)
O more intense for the last couple of weeks
L across lower back and buttocks radiating to right lower leg
D constantly
C stabbing
A Â Walking or sitting too long
R taking tizandine or lying down in bed on side (can not sleep on back)
T everyday and while sleeping pain in lower backÂ
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ROS
unremarkableÂ
EXCEPT- pain in right wrist and lower back radiating to right lower leg
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PHysical exam:
VITALs BP 112/66, hr 84, resp 18. temp 96.7, weight 269, pulse ox 98%, BMI 47.65
OBESE
Anxious
right wrist nodule at the base of the thumb palm side about 1cm (ganglion cyst)
back pain is elicited when the patient stands up and tries to bend over
other areas unremarkable
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PMH
hypothyroidism, anxiety, irritable bowel syndrome, obesity, HTN
Surgeries Appendectomy -2016, tubal ligation 2015, thyroidectomy 2012
Social history
married with 5 children and works as a medical assistant
NO smoking, alcohol drinking socially 4 times a year
Paternal granddad (died heart attack)
Paternal grandmother (died diabetes complications)
Mother (alive HTN)
father (alive diabetes)
Maternal grandad) (died unknown cause)
Maternal grandmother (alive HTN hyperlipidemia)
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Current medications
Tizanidine 4 mg PO qh (lower back pain)
Buspirone 5 mg PO BID (anxiety)
Metoprolol 25 mg PO QD (HTN)
HCTZ 25 mg PO QD (HTN)
Linzess 290 mcg PO QD (IBS)
 Tylenol OTC as needed pain
Levothyroxine 125 mcg PO QD (HYPOthyroidism)
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SCIENCE
HEALTH SCIENCE
NURSING
NSG 6420 6420