Chief complaint

Chief complaint

Low back pain

PATIENT Kay Salisbury DOB 03/30/1983 AGE 34 yrs SEX Female PRN DP278077

FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

ENCOUNTER

NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 04/05/2017 AGE AT DOS

34 yrs

Not signed

Patient identifying details and demographics

FIRST NAME Kay MIDDLE NAME – LAST NAME Salisbury SSN –

SEX Female DATE OF BIRTH 03/30/1983 DATE OF DEATH – PRN DP278077

ETHNICITY – PREF. LANGUAGE

RACE White STATUS Active patient

CONTACT INFORMATION

ADDRESS LINE 1 4994 Shady Range

ADDRESS LINE 2 – CITY Ossawinamakee

Beach STATE MS ZIP CODE 39469

CONTACT BY – EMAIL – HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE – OFFICE EXTENSION

FAMILY INFORMATION

NEXT OF KIN – RELATION TO PATIENT – PHONE – ADDRESS –

PATIENT’S MOTHER’S MAIDEN NAME

PATIENT NOTES

Prefers that major diagnoses be discussed with her cardiologist Dr. Seifert

Subjective

The patient is a 34-year-old woman who presents with complaints of back pain. She describes the pain as a “dull ache in my lower back and into my right hip.” She is unable to identify any reason for the onset of pain. The pain does not radiate down legs. The patient states that the pain has been present for 2 weeks and is progressively getting worse. No urinary or fecal incontinence. Patient has not had any imaging studies.

She states that sometimes the pain is worst in the morning and other times it bothers her more during the day. OTC anti-inflammatory medication and ice have provided temporary relief.

Objective

Encounter – Office Visit Date of service: 04/05/17 Patient: Kay S… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…

1 of 2 4/5/17, 4:31 PM

 

 

Patient’s blood pressure is 116/78. Patient’s HR is 80 bpm and regular. Pain is rated 5/10 while resting and 7/10 while standing and walking. Lumbar spine ROM is limited to 50 degrees of flexion. All other lumbar ROM tests are WNL. Physical exam indicates bilateral lumbar muscle spasm and hypertrophy.

Assessment

DDX: Lumbar strain with radiculopathy into the right hip and posterior thigh. Possible unilateral vertebral disk herniation or DJD of lumbar spine.

Lumbar strain [847.2]. Lumbar pain [724.2].

Plan

Patient is encouraged to continue OTC anti-inflammatory medication b.i.d. Patient will be referred for lumbar and sacroiliac radiography. Radiographic findings will determine the need for follow-up MRI or physical therapy referral. The patient was given a handout on gentle low back stretches and was encouraged to try several gentle yoga positions at home.The patient should return to the clinic in one week.

Free cloud based EHR

Encounter – Office Visit Date of service: 04/05/17 Patient: Kay S… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…

2 of 2 4/5/17, 4:31 PM

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