Tina Williams " Acute Low Back Pain" iHuman

Tina Williams " Acute Low Back Pain" iHuman

History & Physical Examination
SOAP #4 2
Patient Demographics:
Name: T.H.
Age/race/sex: 26 Hispanic Female
Clinical site: Primary Care clinic; Presents for sick visit.
SUBJECTIVE DATA
Chief Complaints : “My lower back has been hurting for about 2 weeks now”.
History of Present Illness :
Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline,
who presents to the clinic today complaining of spontaneous occurring acute low back pain to
lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has
been very difficult to dress lower body and to bend. She reports the pain is constant but has
intermittent intensities of aching and soreness throughout the day. The pain is localized to the
lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today
with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has
experienced. Reports the pain is worse in the mornings when getting out of bed after lying
down all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She
reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or
depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped
head first over the handle bars of the bike. At which time she experienced this same low back
pain, went to the ER and had X-rays that showed some inflammation and swelling. She was
then prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped
tremendously. At today’s visit, she hopes to find out where the pain is coming from and what
she can do to prevent it from returning. 

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