History of Present Illness (HPI)
A 58-year-old female presents for severe back pain, the onset of which was 5 days ago. Pain character is aching, and it starts and stops at irregular intervals. Among the associated signs and symptoms, there are nausea, fatigue, morning stiffness, and fever. Timing is irregular as pain occurs in the morning and after inactivity periods. The patient notes that back trauma is an exacerbating factor, and she has little relief after medication intake. Severity is 10/10 on the pain scale.
Medications: Metoprolol (hypertension); Metformin and Prandin (diabetes). Previous medications for back pain after trauma were Flexeril, Naprosyn, and Percocet.
Allergies: Citrus allergy (anaphylaxis).
Past Medical History (PMH): Chickenpox and measles; hospitalization for N1H1 virus (swine influenza) in 2009.
Past Surgical History (PSH): Appendectomy in 2012.
Sexual/Reproductive History: The patient has the history of 3 pregnancies and 2 births (G3P2A1). Currently, she has menopause, uses the interrupted intercourse method of contraception. The patient reports about her active sexual functioning and having only 1 partner.
Personal/Social History: No alcohol or tobacco use, eating habits are unhealthy as the patient prefers fast food, exercising is absent, and she is interested in design and architecture. Both ADL’s and IADL’s are present.
Immunization History: Influenza immunization in 2017.
Significant Family History: Grandparents died in the car accident and suffered from hypertension. The patient’s mother has diabetes, while her father died from a myocardial infarction. Her two sisters have hypertension and obesity. One of daughters is also obese, and the other one has citrus allergy.
Lifestyle: The patient is a White Catholic, who values family and ethnic traditions. She has a middle income, lives in a safe neighborhood, and heterosexual.
Review of Systems
General: Fatigue, fever no weight changes or chills.
HEENT: Eyes: no changes in vision. Ears, Nose, Throat: No sneezing, tinnitus, hearing problems, changes in smelling, discharges, or sore throat.
Neck: No concerns.
Breasts: No calcifications or breast cancer symptoms.
Respiratory: Regular respirations, no chest pain or dyspnea.
Cardiovascular/Peripheral Vascular: No edema, murmur, or palpitations; hypertension.
Gastrointestinal: Nausea, mild epigastric tenderness.
Genitourinary: No changes in bladder control or urination patterns.
Musculoskeletal: Severe back pain, stiffness (especially in the morning), back trauma after the car accident.
Psychiatric: Depression after the car accident during half a year.
Neurological: No dizziness or tingling.
Skin: No rash or tenderness.
Hematologic: No anemia, blood transfusion, or bleeding.
Endocrine: Diabetes, increased sweating.
Allergic/Immunologic: Citrus allergy.
Objective Data
Physical Exam
Vital signs: B/P 150/90, right arm, sitting, regular cuff; P 70 and regular; T 103.5 orally; RR 16; non-labored; Wt: 170 lbs; Ht: 5’8; BMI 26
General: NAD, A&O x3; posture, motor activity, and gait, facial expression, and level of consciousness are adequate. The patient is alert and oriented.
HEENT: EOMI, PERRLA.
Neck: Symmetric, no thyromegaly.
Chest: Palpation reveals no seals.
Lungs: Breathing is clear, no wheezing and other atypical sounds.
Heart: ECG – HR – 75 BPM, HR – regularly irregular, cardiac axis without deviations.
Peripheral Vascular: Abdomen: Abdominal ultrasound reveals no problems.
Genital/Rectal: Genital ultrasound shows several small cysts.
Musculoskeletal: X-rays of pelvis and back presents deformation of 2 vertebras, reactive sclerosis, ankylosis, and bridging of the pubic symphysis; MRI helps to detail the inflammation area, including its size and location; lab tests: complete blood count (CBC) shows the presence of inflammation in the body (increase in the number of leukocytes), biochemical analysis confirms inflammatory processes in the body (increase in C-reactive protein).
Neurological: No health issues.
Skin: No health issues.
Assessment
- Ankylosing spondylitis. It is a chronic systemic lesion of the joints, predominantly of sacroiliac joint and paravertebral soft tissues, where inflammatory processes have an immunological etiology (Rosenbaum, 2015). The disease can be asymptomatic for years, disturbing only with aching pains in the back and the overall fatigue (Buttaro, Trybulski, Polgar Bailey, & Sandberg-Cook, 2017).
- Diffuse idiopathic skeletal hyperostosis (DISH). It is characterized by the proliferation of bones (hyperostosis) at the sites of attachment of tendons and ligaments (Mader, Verlaan, & Buskila, 2013). There are no typical signs of the disease; however, when the spine is affected, stiffness in the back or neck is noted.
- Vertebral fracture. The instability of the vertebral section may lead to mechanical pain and spinal deformity (Mader et al., 2013). The patient has no recent trauma.
- chronotic arthropathy. There are changes in joints that occur due to receptor sensitivity disorders that may be damaged due to diabetes mellitus, infections, et cetera (Acar et al., 2013). The disease is differentiated by the existence homogentisic acid in the blood.
- Osteoarthritis. It appears due to the mechanical destruction of normal joint structures, capsule alterations, and harm to the cartilage. Pain in the joint has a tendency to increase with loads and decrease after rest.
- Rheumatoid arthritis. An autoimmune disease of unknown etiology is characterized by the symmetrical damage to cartilage and bone tissue (Rosenbaum, 2015). Primary symptoms may include fatigue, weakness, slight fever, loss of appetite, and inflammation of the salivary glands.
- Avascular necrosis. It is a disease in which the necrosis of bone tissue occurs due to circulatory failure. Symptoms are joint pain during exercise or at rest and the violation of the functionality of the joint, as a result of which there is a restriction of movements (Ma, Chan, & Carruthers, 2014).
- Fibromyalgia. This extraarticular disease of unknown etiology is marked by generalized pain, the source of which is fibrous and muscular tissue of any localization (Ma et al., 2014). Many patients have irritable bowel syndrome, interstitial cystitis, or tension headaches.
Plan
Treatment Plan
For ankylosing spondylitis, nonsteroidal anti-inflammatory drugs (NSAIDs) should be used in combination with Disease-modifying antirheumatic drugs (DMARDs) to reduce stiffness, pain, and inflammation (Ward et al., 2016). Namely, Ortofen (150 mg per day for 1 month) and Rheumatrex (twice per week for 1 month) should be prescribed. As for non-pharmacological treatment, one may note thermotherapy and back massage, as well as surgery as an alternative treatment in case if medication will be ineffective. The patient should receive a follow-up consultation within 3 weeks to ensure that treatment was chosen appropriately (Ward et al., 2016). No additional labs, X-ray, or diagnostics are required. It is important to refer the patient to a gynecologist for further examination of cysts that were detected during ultrasound. Diabetes and hypertension are controlled. Discontinued medications are Flexeril, Naprosyn, and Percocet. In one month, X-ray should be repeated.
Health Promotion
Rest and restriction of physical exercises are important for health promotion. The patient’s bed should be even and hard, and it is recommended to abandon pillows and rollers under the neck at least for half a year. In the future, a thin cushion is allowed (Ward et al., 2016). She needs constant emotional comfort, a balanced diet, and quality sleep in a relaxed position. Swimming is also a good health promotion measure to strengthen the back.
Disease Prevention
Considering the patient’s age and personal history, she is recommended to avoid fast food and take adequate physical exercises after the acute period of the disease (Ward et al., 2016). Influenza immunization, mammography, and weight control.
Reflection
This assignment taught me to differentiate between diagnoses that are related to back pain. I have learned that the additional tests and diagnostics are critical to determine proper diagnosis and prescribe the corresponding treatment. This comprehensive SOAP note allowed me to examine the patient’s body systems with the help of the evidence-based research, thus improving my skills and knowledge in the given field.
References
Acar, M. A., Erkocak, Ö. F., Aydin, B. K., Altan, E., Şenaran, H., & Elmadağ, N. M. (2013). Patients with black hip and black knee due to ochronotic arthropathy: Case report and review of literature. Oman Medical Journal, 28(6), 448-449.
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.
Ma, V. Y., Chan, L., & Carruthers, K. J. (2014). Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: Stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Archives of Physical Medicine and Rehabilitation, 95(5), 986-995.
Mader, R., Verlaan, J. J., & Buskila, D. (2013). Diffuse idiopathic skeletal hyperostosis: Clinical features and pathogenic mechanisms. Nature Reviews Rheumatology, 9(12), 741-750.
Rosenbaum, J. T. (2015). Uveitis in spondyloarthritis including psoriatic arthritis, ankylosing spondylitis, and inflammatory bowel disease. Clinical Rheumatology, 34(6), 999-1002.
Ward, M. M., Deodhar, A., Akl, E. A., Lui, A., Ermann, J., Gensler, L. S.,… Inman, R. D. (2016). American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis research and treatment network 2015 recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis & Rheumatology, 68(2), 282-298.