Focused SOAP Note for Sciatica Management, Assignments of Nursing

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FOCUSED SOAP NOTE

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/ 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

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 225lb. BMI: 28. GENERAL: Alert and oriented x 3. Normal affect. No apparent distress noted SKIN: No rash, itching, or lesions noted

CARDIOVASCULAR: RRR. S1S2 on auscultation. No murmurs, gallups, or rubs RESPIRATORY: Normal respiratory effort. No crackles, rhonchi, rales, or wheezes GASTROINTESTINAL: BS present x 4. Non tender on palpation NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Right lower back pain. Pain radiates to the right popliteal fossa.

• right straight leg test, pain along the sciatic nerve at 50 degrees of hip flexion NEUROLOGICAL: Antalgic Gait. No numbness or loss of sensation Diagnostic results : Straight leg raise test (SLR)- For patient’s with low back pain, the SLR test is recommended to determine radicular pain (Nee et al., 2022). A. Sciatica (ICD-10 Code right side M54.31)- Sciatica is the result of compression and =/or irritation of the sciatic nerve (Aguilar-Shea et al., 2022). The pain normally radiates along the sciatic nerve and is described as sharp or burning (Aguilar-Shea et al., 2022). The patient’s pain starts from the buttock and radiates down to the back of his right leg. Patient is overweight, works from home, and sits most of the day. Patient with positive right straight leg raise test and limping gait. Denies bowel or bladder changes. Pain is described as “stinging”. Differential Diagnoses: Herniated lumbosacral disc (ICD- 10 Code M51. 26)- signs and symptoms include lower back pain, leg weakness, and leg pain that is worse with movement. Risk factors include being overweight, men between the age of 20 to 50 years of age, and a sedentary lifestyle (The Difference between Bulging Disc and Herniated Disc, 2019). According to the American Association of Neurological Surgeons (2019), disc herniation is often preceded by sporadic episodes of low-back pain. Patient’s last account of back pain is 10 years ago. Muscle strain (ICD-10 Code S39. 012A)- the overstretching or injury to a muscle or tendon can lead to muscle strain. A strained muscle can have pain that radiates to the buttock but typically does not affect the legs (Low Back Strain and Sprain – Symptoms, Diagnosis and Treatments, 2023). This pain and can

Cauda equina syndrome (ICD- 10 Code G83.4)- is the compression of the cauda equina nerve roots. This is a must-not-miss diagnosis as it can require surgical intervention to correct. Symptoms include unilateral or bilateral back pain, lower extremity weakness, and bowel and/or bladder incontinence. The patient’s back pain is unilateral, he denies loss of bowel or bladder control, and denies loss of sensation to lower extremities. P. Prescribed medication : Medrol (Methylprednisolone) Dose pack 4mg- take as directed x 6 days. No refills. Cyclobenzaprine 5 mg 1-2 tabs by mouth up to 3 x per day x 7 days. No refills. Tylenol 1,000mg by mouth every 4-6 hours as needed for muscle pain Disposition of the patient, Therapeutic Interventions, Education , and follow-ups Discharge home. Rest. Cyclobenzaprine- can make you drowsy. Do not operate machinery or drive after taking this medication Avoid NSAIDs (ibuprofen, Naproxen) while taking your Medrol Dose pack Alternate ice and heat therapies every 20 minutes Warm soaking baths Heating pad on warm for no more than 30 minutes at a time Take breaks at your desk to stretch your back every hour Think about investing in standing desk Seek emergent medical care if you develop: new or worse pain, numbness to your legs or buttocks, tingling, lower extremity weakness, loss of sensation, loss of bowel or bladder function. If you are not noticing any improvement in one to weeks call the office for referral to orthopedic spin specialist for imaging and physical therapy

Reflection My primary diagnosis for this patient was sciatica and my preceptor agreed. The patient reported right, lower back pain that radiated down his buttock to the back of his right knee. The pain was constant and described as “stinging”. He denied any injury or known cause for the back pain. His pain worsened when he was sitting or changed position from sitting to standing. Upon examination he had a positive straight leg raise on the right side. According to Aguilar-Shea et al. (2022), non-pharmacological treatment options for sciatica include exercise, stretching, maintaining appropriate back posture, warm heat, and cold therapies. Appropriate pharmacology therapies include the use of muscle relaxants, systemic corticosteroids, and non-steroidal anti-inflammatory drugs (NSAIDs) (Aguilar- Shea et al., 2022). However, if prescribed a corticosteroid, the patient should not take an NSAID. After completing the patient’s history of illness, I immediately considered sciatica as the patient’s diagnosis. My “aha” moment occurred when I performed the SLR test, and the patient had pain to the affected side. Had the patient reported an injury or fall, I would have wanted to get an x- ray, but other than that, I would not change or have done anything differently in evaluating a patient with similar symptoms. I performed a thorough examination on this patient and asked question that ruled out a must-not-miss diagnosis.

0 throughout his day to stretch his back and legs. The patient should also ensure he has an ergonomically designed desk and chair. Regularly exercising and strengthening his core muscles will help to strengthen his back. Additionally, losing weight will decrease the amount of pressure on his lower back and sciatic nerve.

1 References Aguilar-Shea, A., Gallardo-Mayo, C., Sanz-González, R., & Paredes, I. (2022). Sciatica. Management for family physicians. Journal of Family Medicine & Primary Care, 11(8), 4174–4179. https://doi.org/10.4103/jfmpc.jfmpc_1061_ American Association of Neurological Surgeons. (2019). Herniated Disc – Symptoms, Causes, Prevention and Treatments. Aans.org. https://www.aans.org/Patients/Neurosurgical- Conditions-and-Treatments/Herniated- Disc Low Back Strain and Sprain – Symptoms, Diagnosis and Treatments. (2023). Www.aans.org. https://www.aans.org/Patients/Neurosurgical-Conditions-and- Treatments/Low-Back- Strain-and-Sprain Nee, R. J., Coppieters, M. W., & Boyd, B. S. (2022). Reliability of the straight leg raise test for suspected lumbar radicular pain: A systematic review with meta-analysis. Musculoskeletal Science and Practice, 59, 102529. https://doi.org/10.1016/j.msksp.2022. The Difference Between Bulging Disc and Herniated Disc. (2019, November 6). Miamineurosciencecenter.com. https://miamineurosciencecenter.com/en/conditions/herniated-disc/