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Asked by MateApeMaster380

SOAP needed w/ 3 three differential diagnoses and resources 

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  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 back 

 

ROS

unremarkable 

EXCEPT- pain in right wrist and lower back radiating to right lower leg

 

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

 

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)

 

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)

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NSG 6420 6420