Case No.

:
Date:

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLAN

PROBLEM

1.VITAL SIGNS
2.LAB TESTS
3.MED.LIST

ETIOLOGY OF PROBLEM

1.EVALUATE CURRENT
THERAPY FOR
PROBLEM
2.EVALUATE NEED FOR
THERAPY

LOW BACK PAIN

Vitals:

The majority of LBP does not

1) Tramadol centrally

(LBP) / LUMBAGO

PR:76/min

have a clear cause but is

acting analgesic relieves

pain by

and drug treatment

Pay attention to the

believed to be the result of

pain

surgery.

includes Tramadol and

body, Pain is a warnin

B.P: 120/70 mm of Hg

GOALS FOR
TREATMENT
OF PROBLEM

PATIENT
EDUCATION

Reduce the

RECOMMEND
1. DRUG TREATMENT FOR
PROBLEM
2. MONITORING
PARAMETERS FOR EACH
DRUG LISTED
3. FURTHER TESTS FOR
PROBLEM IF NEEDED
4. DRUGS TO BE AVOIDED
AND WHY
1) Surgery is recommended

Advice the patient to

36 y/o male , was

Abdomen : Soft ,

non-serious muscle or

Ceftriaxone Surgical

other surgical prophylaxis

Ask him/her to discus

admitted on

Bowel sounds +

skeletal issues such as

Prophylaxis

(Antibiotics, Antacids & IV

the activity with doct

26/06/2014 with c/o

RS : Clear

sprains or strains. Obesity,

Ondansetron & Ranitidine

Pain in back since 20

GC : Fair

smoking, weight gain during

Hcl - To prevent nausea,

days

Spine:

pregnancy, stress, poor

vomiting, or other

Pain is radiating to

Straight Leg Raise (SLR)

physical condition, poor

complications from acid

belt hip up to left foot

Test : + 60 degree for left

posture and poor sleeping

being produced but not

, difficulty in walking ,

leg & Negative for right

position may also contribute

used in patient undergone

sitting

leg

to low back pain.

surgery

Rx : Limbo Physio Traction

In this case, Low back pain

PMH: h/o heavy

weight lifting,

Current medication:

5months back by

Inj. Tramadol

bending forward

BD

IV

fluids
2) Muscle relaxant can be

IV fluids, are given to

L5 S1

patients for two primary

reasons, to replace fluids

before proceeding

added

Sit & Sleep Comfortab

2)For Tramadol monitor
respiratory rate & blood

and be sure that lowe

back is supported

pressure and For Ondansetron

blood pressure monitoring is

due to Slipped disc L3, L4 ,

or physiotherapist

Lose weight if Obese

required
3) X Ray- Discogram, MRI
4) Nil

Lift Properly: DO not l

heavy loads by placin

they have lost through

pressure on lower bac

illness or injury, or to

Use legs to lift and

OD

provide fluids when they

always bend your kne

Inj. Ondansetron 4mg IV

are unable to drink as

so your arms

Inj. Cefrioxone

1gm IV

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA

Case No.:
Date:

SOS
Inj. Ranitidine HCl

they normally would

IV

BD
T. Tramadol HCl

p/o

BD
I.V. Fluid
40ml/hr

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA