Soap notes
02/05/2023
A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years
S:
C/O lower back pain relieving a little(25%) on taking medication.
Patient not compliant on NSAID (etoshine mr)due to bloating.
O/E:
Temp- Afebrile
BP-130/70mm hg
PR-86 bpm
Rr-16 cpm
Spo2- 99% on RA
General examination:
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
A:
55 years old female with ? Lumbar spondylosis
P:
TAB. ETOSHINE MR PO/BD
TAB. PAN 40mg PO/OD
TAB. REJUNEX CD3 PO/OD
TAB. PREGALIN-D 75/30 PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG)
TAB . AMLODIPINE 5mg PO/OD
TAB. SHELCAL CT PO/OD
Soap notes
3/05/2023
A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years
S:
C/O lower back pain present same as to yesterday ,relieved a little on medication
Stools passed
O:
Temp- Afebrile
BP-110/70mm hg
PR-76 bpm
RR-14 cpm
SPO2- 99% on RA
General examination:
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
A:
55 years old female with ? Lumbar spondylosis
P:
TAB.ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG)
TAB . AMLODIPINE 5mg PO/OD
TAB. SHECAL CT PO/OD
TAB .CLONEZEPAM 0.25mg
(Of sleep disturbance present )
lumbar back support (BECT)
Soap notes
4/05/2023
A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years
S:
Pain reduced
Stools passed
O:
Temp- Afebrile
BP-110/70mm hg
PR-76 bpm
RR-14 cpm
SPO2- 99% on RA
General examination:
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
A:
55 years old female with ? Lumbar spondylosis
P:
TAB.ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG)
TAB . AMLODIPINE 5mg PO/OD
TAB. SHECAL CT PO/OD
TAB .CLONEZEPAM 0.25mg
(Of sleep disturbance present )
lumbar back support (BECT)
Soap notes
05/05/2023
A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years
S:
C/O lower back pain decreased compared to yesterday
Stools passed
O:
Temp- Afebrile
BP-110/70mm hg
PR-76 bpm
RR-14 cpm
SPO2- 99% on RA
General examination:
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
A:
55 years old female with ? Lumbar spondylosis
P:
TAB.ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG)
TAB . AMLODIPINE 5mg PO/OD
PSYCHIATRIC REFERRAL (30/04/2023)
This is a case of a 53-year-old female with lumbar spondylosis. The patient is having sleep disturbances and is taking tablet HICLAM plus since five years for sleep at bedtime. The patient is habituated to take medications frequently for unknown complaints. Patient is referred to us in view of further evaluation,
history of presenting illness,
patient was apparently alright around 15 to 20 years ago, then one fine day, she noticed having constant back pain (lower) and with passing of time the pain progressed to left leg up two left feet. She complained of pain and tingling sensation. then she consulted a doctor, who, after various investigations told the patient that her vertebral column (lower back, vertebra-lumbar ) changes were seen and heard. Changes were seen and were kgetting compressed Thus the pain was seen and is radiating to her. Lower back. She was given treatment, along with painkillers. Since then she is consuming painkillers almost daily. She has sleep disturbances (initiation of sleep) due to her lower back pain but is fine once she sleeps. She used to do farming work then, and used to go to the work and daily.
For the next 4 to 5 years, she consulted various doctors to relieve her pain and for better treatment. In this period, she started complaining pain in the upper back (both sides), neck, pain over the face (bilaterally), bilateral eye pain, swollen eyes, headache, tingling, sensation, overhead/scalp, unilateral or bilateral headaches of various intensities , sometimes she complained of having something in her head (she had the sensations) she consulted a neurosurgeon for the said complaints, 10 to 11 years ago, after multiple test, including CT scan done, according to the, OD.
Doctors told them that changes were seen in the CT scan and that some problem was there. And since then she was started on tablet HICALM plus along with her previous medications, for lower back pain. This tablet also help her with her sleep disturbances. She is able to sleep better with that tablet so she started using tablet. HICALM plus daily since 10 to 11 years.
She later consulted various doctors (more than 10) in the last 10 to 15 years as her complaints didn’t subside and no treatment was relieving Herpen totally, and that no doctor was finding the cause. She tried various medications, and she is tensed if she is not taking any medication. If she doesn’t replenish her medications once when over, then she misses taking tablets for few days. She feels tensed and irritable and busters her family to get the tablets as soon as possible.She feels that she needs medicine to live a proper life every day as medicines, relieve her of pain, and she feels better. She stopped working as farmer-made since last five years, due to pains and also financial stability-support given by her children. She does daily chores in her house, self care and hygiene. Maintained . Appetite is normal. She is currently using tablet ETORICOXIB, NEXPRORD, tablet, SULSASALAZINE, tablet HICALM plus,
She can’t sit for long time due to the pain, physical/mental stress. Is increasing her pain sensation. She doesn’t have any relieving factors for her pain other than medications, she constantly thinks about her health, her pains, that she is not able to have a normal life like others, her age due to the pain. She feels low regarding her condition since past 10 years, and she has become less energetic and feels her body has become fragile. She constantly also thinks about her family members, since last 5 to 6 years, she is not able to tolerate loud noises, she gets sick and her pains increase when exposed to loud Noises, no history of head, injury, seizures,
no history of substance, abuse,
no history of hearing of voices, says, talking, self, smiling behaviour,
no history of suicide, ability,
no history of grandiosity, flight of ideas, no history of fear, impending, doom, palpitations,
no history of repetitive thoughts, actions
Past history-
known case of hypertension. Since 10 years uses tablet amlodipine
Family history-
no psychiatric history in the family
On examination
BP-110/70, mmHg
Pulse rate-84 beats per minute
Respiratory rate-19/minutes
Temperature-a febrile
Patient is unable to sit on the chair comfortably for longer duration (more than 10 minutes) due to lower back pain. Patient is moderately built well-kept and responding well to oral commands.
ETEC + and sustained
PMA-normal
Rapport established
RT-normal relevant and coherent
Speech-T ,V,R-normal
Thoughts-constantly things about her pain
Mood-‘dare hai” Lekin accha hai
Effect-Euthymic
Perception-NAD
Oriented to time, place and person
IMPRESSION -1) persistent somatoform disorder in background of physical illness
2)mild depressive episode
PLAN
1. O D. PSYCHO EDUCATED
2. TAB PREGABLIN plus duloxetine, 30 mg.(PREGALIN-D-30).
3. TAB clonazepam 0.25mg/po/(if sleep disturbances present)
4. Stop T. HICALM plus.
PSYCHIATRIC FOLLOW UP (1/05/2023)
Patient is seen complaint on medication took night dose of medication, of medication
Reports to have slept well last night (9:30 PM to 5 AM)
Appetite is normal
No fresh complaints
Patient is sitting on the bed in uncomfortable way as she has back pain. Responding well to oral commands.
ERC +, maintaineded
P M. A-normal
Speech, T, R normal.
R T.-NORMAL, RELEVANT AND COHERENT
THOUGHT-ABOUT HER HEALTH
WORD-‘ACHA HAI’
AFFECT-EUTHYMIC
PERCEPTION, NAD
ORIENTED TO TIME, PLACE, PERSON
1) patient and OD counselled
2) continue medications by neurosurgeon. (gabapentin, duloxetine )
With hold TAB. Pregalin-D
PSYCHIATRY, FOLLOW-UP NOTES (2/05/2023)
Patient seen complaint on medication, but took psychiatric medication along with neurosurgery medication (psychiatry, medication was stopped yesterday)
Reports to have slept well last night
Appetite-normal
No fresh complaints
Patient and O D. Strictly counselled to follow treatment accordingly as per plan.
MSE : GAB: patient is sitting on the chair uncomfortably. Due to her back pain, responds well to oral commands.
ETEC +, sustained
P M.A-normal.
Speech-TV R. Normal
RT-normal relevant and coherent
Thought-about her operation Food issue (north, South difference)
Mood-Accha Hai
Affect- Euthymic
Perception-NAD
PSYCHIATRY s, FOLLOW-UP NOTES (3/05/2023)
Patient seen complaint on medication
Took night doors of medication
Report to have slept well last night
Appetite-Normal
No fresh complaints
MSE-patient is sitting on the bed and responding to oral commands
ETEC-present
P M. A-Normal
Speech-TVR-Normal
RT-normal relevant and coherent
Thought-worried about her health
Mood-Accha Hai
Affect- Euthymic
Perception-NAD
Oriented to time, place and person
DISCHARGE SUMMARY
Final diagnosis
DISCHARGE SUMMARY
Final diagnosis
Low backache 15 years
Headache 5 years
IMPRESSION -
1) persistent somatoform disorder in background of physical illness
2)mild depressive episode
3)Hypertension 10 years
A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years
patient was married at the age of 18 years ,non consanguineous marriage,she did not receive any form of education ,started working in the farms 4 years after her marriage involving ploughing and sowing ,transplanting the sampling requiring her to bend foward and lean for several hours (5-10hrs/day)
She was apparently asymptomatic 15 years back when she developed low back ache ,which was insidious in onset and gradually progressive , radiating type ,to both the lower limbs more on left side ,more in the calf muscles ,associated with tingling and numbness more the the right side .Pain aggravates on sitting ,she is unable to sit for long durations
PAST HISTORY
K/c/o of Hypertension since 10 years
k/c/o cervical spondylisis since 8 years
COURSE IN HOSPITAL
Patient was investigated further and was found to have persistent somatoform disorder in background of physical illness with mild depressive episode,patient and OD were pyscho educated
Patient was reffered to opthalomogy department to rule out hypertensive retinopathy ,patient didn’t show any signs of following .
Patient on referral to neurosurgery was prescribed TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG) ,lumbar back support belt
Advice surgery L4-L5 L5-S1 laminectomy and discectomy
patient and OD counselled to continue medications by neurosurgeon. (gabapentin, duloxetine )
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