NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note
Patient Information:
JW, a 62-year-old black female presents with chronic lower back pain.
S.
CC (chief complaint): Chronic lower back pain.
HPI: JW has been experiencing pain for several months, which occurs after a day of hard work. Her work consists of lifting with a back brace at times, but in the last two months, there is a restriction placed, and she has been undergoing physical therapy to provide strength. The pain affects her ability to move and work effectively. The severity of the pain is 4/10, and medication and pain therapy make the pain subside.
Current Medications: Tylenol and hydrocodone
Allergies: No known drug allergies or reactions to changes in weather such as cold or heat, dust, or pollen.
PMHx: JW’s immunization details, including a flu shot, are up to date.
Soc & Substance Hx: JW has no history of drug or substance abuse. She lives alone but receives adequate support from her family. She wears safety belts while driving and does not use a mobile phone while driving.
Fam Hx: Her mother, aged 92, suffers from hypertension, and her father, aged 95, suffers from diabetes. She has one brother who has diabetes. One of her children died in a car accident seven years ago. She has no grandchildren.
Surgical Hx: JW was diagnosed with back pain ten years ago and underwent laminectomy to address lumbar spinal stenosis.
Mental Hx: JW has a history of a mental problem after her child died seven years ago. She has been undergoing treatment to address post-traumatic disorder due to trauma she experienced at work in her first job as a firefighter.
Violence Hx: She has no history of sexual or physical violence.
Reproductive Hx: JW’s LMP was 13 years ago. She has two children but one died seven years ago. She is a single mother but was sexually active with multiple partners until ten years ago when she quit her job as a firefighter. She relocated and stopped seeing her sexual partners. No sexual health complications.
ROS:
GENERAL: No unexpected weight loss of gain, fever, fatigue, or chills.
HEENT: Eyes: No visual complications or yellow sclerae. Ears, Nose, Throat: No hearing difficulties, sneezing, nasal congestion, or sore throat.
SKIN: No skin rashes, lesions, or itching.
CARDIOVASCULAR: No chest pressure, palpitations, or chest discomfort.
RESPIRATORY: No cough, sputum, or shortness of breath.
GASTROINTESTINAL: No vomiting, diarrhea, nausea, or abdominal pain.
GENITOURINARY: No pain or burning sensation during urination. JW had two pregnancies thirty years ago. LMP: 04/27/2005.
NEUROLOGICAL: No headache, numbness, dizziness, or inappropriate control of the bladder.
MUSCULOSKELETAL: Chronic lower back pain.
HEMATOLOGIC: No bleeding, anemia, or bruising.
LYMPHATICS: No history of splenectomy or enlarged nodes.
PSYCHIATRIC: JW has a history of post-traumatic disorder.
ENDOCRINOLOGIC: No history of cold and heat intolerance or polyuria.
REPRODUCTIVE: Last pregnancy was 30 years ago. No vaginal discharge. She is not sexually active.
ALLERGIES: No history of rhinitis or asthma.
O.
Physical exam:
Vital signs: 127/67, 78. 97.4, 18.
Neurological: A, A & O.
Skin: Warm and dry skin. No open wounds, lesions, or skin rashes.
Lungs: No abnormalities and clear lungs bilaterally.
Cardiovascular: Optimal heart rate and sounds.
Abdomen: No hyperactive bowel sounds.
Peripheral vascular: No edema.
HEENT: No visual complications, or yellow sclerae. Ears, Nose, Throat: No hearing difficulties, sneezing, and nasal congestion, or sore throat.
Musculoskeletal: Chronic lower back pain. History of laminectomy to address lumbar spinal stenosis.
Diagnostic results:
An X-ray is crucial to examine the condition of the spine. An X-ray shows the level of wear and tear in the spine (Fjeld et al., 2019). An MRI is important since it can examine conditions such as herniated lumbar disc that is hard to diagnose with an X-ray. Another role of MRI is to examine the presence of overgrown bones and problems with herniated discs (Berry et al., 2019). A CT scan is another important diagnostic test to examine the cause of lower back pain and rule out other possible conditions (Lafian & Torralba, 2018). Some of the conditions that trigger lower back pain are spinal column damage or pressure on the back. The diagnostic tests are important in examining the cause of the lower back pain.
A.
Differential Diagnoses
1. Herniated lumbar disc
A herniated lumbar disc can occur for no reason or when individuals lift heavy objects that exert pressure on the back (Fjeld et al., 2019). The risk of the condition rises as people advance in age. A medical history, physical examination, X-rays, and CT scan are sufficient to diagnose the condition.
2. Spinal stenosis
Spinal stenosis is a condition that occurs due to the narrowing of the spine. The condition occurs mostly in the lower back and neck. Gradual wear and tear are common among people above 50 years, who are at a higher risk of spinal stenosis (Lafian & Torralba, 2018). Physical examination and X-rays are important diagnostic tests for the disease.
3. Sciatica
The condition occurs from the pain that radiates from the sciatic nerve. The condition occurs as a result of pressure on the nerve by a herniated disc (Zibis et al., 2018). Physical examination and medical history are adequate diagnostic procedures.
4. Muscle strain
The condition occurs when the lower back muscles are strained and torn. A muscle strain occurs due to overuse, inappropriate use, and fatigue (Zibis et al., 2018). Physical examination, medical history, and X-rays are sufficient to diagnose a patient with a muscle strain.
P.
The patient is likely suffering from a herniated lumbar disc. The patient will be referred to a physiotherapist for deep tissue massage, exercise, and hydrotherapy. The patient should continue taking the pain medication and follow up the physiotherapy sessions (Berry et al., 2019). The patient should return to the clinic after one week for observation and review. Patient education about adherence to the treatment is essential.
In future, it will be important to advise a patient to change their lifestyle since it can lead to adverse outcomes. Change of lifestyle will prevent further harm on the back. For example, the patient should indicate some of the activities that strain the back and other body muscles.
The incidence of a herniated lumbar disc is 5 to 20 people for every 1000 people (Fjeld et al., 2019). The condition is common among people from 30 years and above. One of the prevention measures is to change lifestyle. One of the reasons is that as people age, disc wear and tear leading to tearing and rapturing. However, some people cannot identify a single incident that caused the herniated lumbar disc.
References
Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A review of lumbar radiculopathy, diagnosis, and treatment. Cureus, 11(10).
Fjeld, O. R., Grøvle, L., Helgeland, J., Småstuen, M. C., Solberg, T. K., Zwart, J. A., & Grotle, M. (2019). Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation. The bone & joint journal, 101(4), 470-477.
Lafian, A. M., & Torralba, K. D. (2018). Lumbar spinal stenosis in older adults. Rheumatic Disease Clinics, 44(3), 501-512.
Patel, D. R., & Kinsella, E. (2017). Assessment and management of lower back pain in young athletes. Translational pediatrics, 6(3), 225.
Zibis, A. H., Mitrousias, V. D., Klontzas, M. E., Karachalios, T., Varitimidis, S. E., Karantanas, A. H., & Arvanitis, D. L. (2018). Great trochanter bursitis vs sciatica, a diagnostic–anatomic trap: differential diagnosis and brief review of the literature. European Spine Journal, 27(7), 1509-1516.
P.
Plan:
Further assess JW’s chronic lower back pain through imaging studies such as X-rays or MRI.
Prescribe non-opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) as needed to manage her pain.
Continue with physical therapy to improve strength and mobility.
Consider referring JW to a pain specialist if her pain persists.
Continue with treatment for post-traumatic disorder to address mental health concerns.
Discuss lifestyle modifications such as exercise, weight management, and avoiding heavy lifting to prevent exacerbation of her back pain.
Schedule a follow-up appointment in one month to assess her response to treatment and modify the plan as needed.
If JW has not had a menstrual period for 30 years, it is unlikely that the vaginal discharge is related to menstruation. However, there are still several possible causes of vaginal discharge in postmenopausal women. These include:
Bacterial vaginosis: This is a condition caused by an overgrowth of bacteria in the vagina. Symptoms can include a thin, white or gray discharge with a foul odor.
Atrophic vaginitis: This is a condition where the vaginal tissues become thin, dry, and inflamed due to a decrease in estrogen levels. Symptoms can include vaginal dryness, itching, and a thin, watery discharge.
Vulvovaginal candidiasis: This is a fungal infection caused by an overgrowth of yeast in the vagina. Symptoms can include a thick, white discharge with a cottage cheese-like texture and itching.
Cervical or endometrial cancer: In rare cases, vaginal discharge can be a symptom of cervical or endometrial cancer.
