healthcare > iHuman > Tina Williams iHuman Case Acute Low Back Pain - latest Update 2023 | Graded A+ (All)
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; Prese... nts 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 [Show More]
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Jul 24, 2023
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