SOAPE Note

S – 13yo girl states she has back pain following falling back into door/doorknob 1-2 days ago while playing with friends. States
she has pain with twisting and bending but not when lying still. Caregivers wanting to know if it’s fractured and if she needs to
go to the doctor.

O – pt sleeping on couch. When asked to ID pain site, points to upper lumbar spine. No sign of swelling, laceration, or other
deformity. Tender upon palpitation. (side note: pt may have scoliosis??? Did not get a good look, but spine looked slightly
curved)

A – suspected bruise to upper lumbar vertebra. Seems unlikely that this situation would lead to a vertebral fx.

P – recommend rest, ibuprophen, and ice (if possible) to minimize swelling and control pain. Have caregivers continue to monitor
pain level and site and report to MD if pain increases or persists for more than a few days, or if swelling or tingling/numbness
in extremities begins. Mentioned to caregivers that if bone is bruised, it may take slightly longer to heal completely than a
normal bruise, and they should continue to monitor for adverse changes. Pt given 325mg prior to my departure (no
ibuprophen available). Also mentioned to caregivers that another 325mg may be given if this dose does not relieve pain.

E – will re-evaluate kesho.