Adolescent Focused SOAP Note

Patient Information: CJ 13 y.o African American M

S.

CC: back pain

HPI: 13 y.o African American male here with his grandfather complaining of left lower back pain. The problem has been happening for the past 2 years intermittently and progressively worsening with each episode. He experiences back pain 3-4 times a week. The episode can last a couple of hours or the entire day. The pain ranges from 6-8/10 in severity. He describes the pain as sharp. He notes the pain radiates down his left lower leg at times. Movement makes the pain worse. He has tried OTC Advil with minimal relief. Patient denies lower extremity weakness or numbness. He denies any injury or trauma to his back prior to the onset of pain.

Current Medications: Epinephrine 0.3 MG/0.3ML Solution Auto-injector - Apply auto-injector pen to middle of outer thigh and press firmly into the thigh until it clicks, PRN anaphylaxis. OTC Advil 200 mg tablets - Take 1-2 tabs PO qday PRN back pain.

Allergies: NKDA. Allergies to peanuts (anaphylaxis).

PMHx: He is up to date on his immunizations. Last Tdap was 2 years ago. No major illnesses. No injuries or hospitalizations.

Soc & Substance Hx: He is a full time student in the 8th grade. He lives with his grandfather, mom, and little sister. No alcohol, tobacco use, or illegal drug use. He always wears his seat belts while riding in a vehicle. He has friends at school and reports no problems with his school performance.

Fam Hx: No genetic diseases. Father history is unknown. Mom is obese with hypertension.

Surgical Hx: None.

Mental Hx: No history of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: No concerns regarding his safety at home. No bullying at school.

ROS:

GENERAL: No weight loss, fever, or decrease in energy level. Positive weight gain (18 lbs in 6 months).

HEENT: No headaches. No vision loss, blurred vision, double vision, or eye pain. No hearing loss or ear pain. No nasal congestion, runny nose, or sore throat……….. Continue