Adolescent Focused SOAP Note, Assignments of Nursing

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Walden University PRAC 6541 - Primary Care of Adolescents and Children Dr. Juanita Allen

Patient Information: CJ 13 y.o African American M S. CC : back pain HPI : 13 y.o African American male here with his grandfather complaining of left lower back pain. The problem has been happening for the past 2 years intermittently and progressively worsening with each episode. He experiences back pain 3-4 times a week. The episode can last a couple of hours or the entire day. The pain ranges from 6-8/10 in severity. He describes the pain as sharp. He notes the pain radiates down his left lower leg at times. Movement makes the pain worse. He has tried OTC Advil with minimal relief. Patient denies lower extremity weakness or numbness. He denies any injury or trauma to his back prior to the onset of pain. Current Medications : Epinephrine 0.3 MG/0.3ML Solution Auto-injector - Apply auto-injector pen to middle of outer thigh and press firmly into the thigh until it clicks, PRN anaphylaxis. OTC Advil 200 mg tablets - Take 1-2 tabs PO qday PRN back pain. Allergies : NKDA. Allergies to peanuts (anaphylaxis). PMHx : He is up to date on his immunizations. Last Tdap was 2 years ago. No major illnesses. No injuries or hospitalizations. Soc & Substance Hx : He is a full time student in the 8th grade. He lives with his grandfather, mom, and little sister. No alcohol, tobacco use, or illegal drug use. He always wears his seat belts while riding in a vehicle. He has friends at school and reports no problems with his school performance. Fam Hx : No genetic diseases. Father history is unknown. Mom is obese with hypertension. Surgical Hx : None. Mental Hx : No history of self-harm practices and/or suicidal or homicidal ideation. Violence Hx : No concerns regarding his safety at home. No bullying at school. ROS : GENERAL: No weight loss, fever, or decrease in energy level. Positive weight gain (18 lbs in 6 months). HEENT: No headaches. No vision loss, blurred vision, double vision, or eye pain. No hearing loss or ear pain. No nasal congestion, runny nose, or sore throat. NECK: No pain, stiffness, or tenderness. SKIN: No rash or itching. CV: No chest pain, chest discomfort, or syncope. No palpitations or edema. RESP: No shortness of breath, cough, or sputum.

correlation between BMI and low back pain (Illeez, et al., 2020). This patient’s BMI puts him in the overweight category. Also note, this patient has gained 18 lbs since his last visit 6 months ago.

2. Strain of muscle of lower back, initial encounter (S39. 012A) - According to the World Health Organization, “20–33% of the world’s population has some form of chronic musculoskeletal pain” that can adversely affect quality of life (El-Tallawy et al, 2021). Chronic musculoskeletal pain in the pediatric population has not been well studied; however, musculoskeletal pain can occur in patients at any age including adolescents (El-Tallawy et al, 2021). 3. Chronic pain syndrome (G89. 4) - Chronic pain symptoms are more likely to persist and fluctuate over time lasting longer than three months (Traeger, Qaseem, & McAuley, 2021). A study found that chronic pain represented 37.5% of primary care visits in a typical week (Carnago, O’Regan, & Hughes, 2021). 4. Sciatica (M54.3) - Patients report pain that is sharp, burning sensation which radiates down the posterior and lateral leg to the foot or ankle (Dains, Baumann, & Scheibel, 2019). This diagnosis is less likely as he reports his back pain is worse than his leg pain. The straight leg raise test performed was negative and he has no sensory deficit. P. Extensive counseling was given about back pain as well as the course of the disease and management. No referrals needed at this time. Patient was given an order to have an Xray-Thoracic/Lumbar Spine PA/LAT. If the xray is unrevealing, then will pursue physical therapy. If pain continues following PT, will consider ordering an MRI. Advised patient to use Motrin 200 mg tablets - take 1-2 tablets PO q6- hours, PRN pain alternating with Acetaminophen 325 mg tablets - take 2 tablets PO q4-6 hour, PRN pain. Encouraged the patient to use nonpharmacologic therapies like stretching, applying heat to the area, and/or relaxation techniques. Patient was educated on proper posture and body mechanics while rotating/twisting. RTC in 10-12 days for follow up test results and further management. Patient and caregiver were instructed to RTC or go to the ED if the condition worsens. Reflection I agree with my preceptor’s treatment plan for this patient. This patient has never addressed this ongoing problem with a provider before, so having an x-ray done first is appropriate. Not to mention that most insurance companies will not cover more invasive testing without an x-ray being done first. I also agree with my preceptor that pursuing an MRI in the future would be beneficial to get a better look at the soft tissues, discs, and nerve roots. I learned that poor posture can lead to spine misalignment which contributes to a majority of back and neck pain in the pediatric population. Healthy weight can help improve low back pain symptoms. This patient’s BMI is 24, placing him in the overweight category. He should focus on exercise and dietary changes to help him achieve his healthy weight. According to the American College of Physicians, therapies to combine with exercise include “acupuncture, mindfulness-based stress reduction, yoga, progressive relaxation, and spinal manipulation” (Traeger, Qaseem, & McAuley, 2021). References Carnago, L., O’Regan, A., & Hughes, J.M. (April 2021). Diagnosing and Treating Chronic Pain: Are We Doing This Right? Journal of Primary Care & Community Health , 12. doi:10.1177/ Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical

diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. El-Tallawy, S. N., Nalamasu, R., Salem, G. I., LeQuang, J. A. K., Pergolizzi, J. V., & Christo, P. J. (2021). Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain. Pain and therapy , 10 (1), 181–209. https://doi.org/10.1007/s40122-021- 00235- Illeez, O. G., Akpinar, P., Bahadir Ulger, F. E., Ozkan, F. U., & Aktas, I. (2020). Low back pain in children and adolescents: Real life experience of 106 patients. Northern clinics of Istanbul , 7 (6), 603–608. https://doi.org/10.14744/nci.2020. Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ , l6273. https://doi.org/10.1136/bmj.l Traeger, A.C, Qaseem, A., & McAuley, J.H. (July 2021). Low Back Pain. JAMA, 326 (3), 286. doi:10.1001/jama.2020.1971 5