Episodic/Focused SOAP Note Template
Case Scenario 1
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg.
Patient Information:
MC, 42yo, Male
S.
CC: lower back pain for the past month
HPI: MC is a 42yo male presented to the provider with reports of lower back pain for the past month. Reports pain radiates to his left leg. Reports pain 6/10 today. Reports the pain is worse with activity and is relieved by laying straight on hard surfaces and with Ibuprofen. Reports not being able to work because of the pain.
Location: lower back
Onset: one month ago
Character: radiating to left leg
Associated signs and symptoms: n/a
Timing: with walking, applying pressure to lower back
Exacerbating/ relieving factors: walking, bending back
Severity: 6/10 pain scale
Current Medications:
Amlodipine 5mg BID
Ibuprofen 800mg BID
Allergies: NKDA, peanut allergy – hives
PMHx:
Hypertension
Reports immunizations up to date as per work place requirements
Past Surgical History
N/A Soc Hx: MC reports being a construction worker, carpenter, married, father of two children, son 14yo plays baseball, 12yo daughter in dance, married for 18 years. Reports never being a smoker, drinks on occasion, last drink three weeks ago after a game his son’s team won a game. Denies illicit drug use.
Fam Hx:
Mother: no illnesses
Father: hypertension, 68yo, diagnosed at 40yo
Brother: no illnesses
Maternal grandmother: died at 72yo, hypertension
Paternal grandmother: living, 80yo, dementia
Maternal grandfather: 81yo, asthma, hypertension
Paternal grandfather: died at 77yo, DM II, hypertension
ROS:
GENERAL: No weight loss, fatigue due to unable to sleep well r/t back pain, no fever, nausea or vomiting.
HEENT: Eyes: denies vision changes.
Ears, Nose, Throat: No hearing changes, denies changes in smell, runny or itchy nose, no throat or neck pain, no difficulty swallowing, no changes in taste.
SKIN: No rash or itching.
CARDIOVASCULAR: denies chest pain, pressure, or discomfort. Denies palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies changes in bowel habits, bloating, discomfort after meals, heartburn
GENITOURINARY: Denies painful urination, able to maintain stream, no frequent urination, no hematuria.
NEUROLOGICAL: Denies headache, dizziness, syncope, numbness or tingling in the extremities.
MUSCULOSKELETAL: lower back pain radiating to the left leg, difficulty walking because of leg pain. Denies pain in upper extremities or right leg. Denies previous musculoskeletal problems.
HEMATOLOGIC: Denies history of anemia, unexplained bruising, or bleeding. Reports few occasional minor accidents at work, described them as normal scrapes, denies previous infections or major work injuries.
LYMPHATICS: denies large lymph nodes
PSYCHIATRIC: Denies depression or anxiety, reports job being low stress
ENDOCRINOLOGIC: Denies sweating unless in the heat, denies chills. Denies polyuria or polydipsia.
ALLERGIES: peanuts – hives, denies swelling or difficulty breathing when accidentally ingesting
O.
Physical exam:
Vital signs:
T- 98.7F
P – 80bpm
RR – 19
BP – 140/78
Height – 6’1â€
Weight – 210lbs
General: A&O x3, verbal and able to make needs known, speech is coherent and clear, well-groomed, and nourished
HEENT
H: normocephalic, hair well distributed, no skin abnormalities noted
E: symmetrically positioned, no redness, no yellowing of the sclera, no discharge, eyelids without droopiness, pink conjunctiva
E: no abnormal findings, ear canal clear, pearly grey tympanic membrane
N: no swelling, trachea at midline, no pain on palpation
T: no difficulty swallowing, no abnormalities
Respiratory: chest symmetric, clear lung sounds auscultated in all lung fields, no cough or shortness of breath
GI: abdomen not distended, active bowel sounds in all quadrants, no masses palpated, tympany
CV: S1, S2 present, regular and strong heartbeats, no edema, capillary refill < 3 sec
GU: no abnormalities, denies inability to maintain stream, or changes in urinary habits
Skin: no rashes, hair evenly distributed on the body, no color irregularities
MS: low back pain radiating to left leg, unable to maintain normal gait d/t pain, bending is difficult d/t pain
Diagnostic results:
Lower spine assessment for nerve root irritation
X-Ray of lumbar spine
CT scan of the cervical and lumbar spine
A.
Differential Diagnoses
1. Sciatica – low back pain radiating to one lower extremity due to compression of the compression of sciatic nerve root. It may be caused by mechanical compression of the sciatic nerve, lumbar disk herniation, neural adhesions, arachnoiditis, or virus-induced mononeuritis (Pesonen et al., 2021). Physical assessment consists in femoral hip stretch to detect inflammation of the nerve root at L1, L2, L3, or L4 level. The patient is prone and asked to extend a hip; presence of pain on extension is a positive sign of nerve root irritation (Ball et al., 2019). Non-pharmacological therapy is aimed to relieve symptoms through exercise and proper use of body mechanics, pharmacological aimed to alleviate pain – NSAIDs, muscle relaxants, opioids, or glucocorticoids, or surgical intervention to relieve pressure (Foster et al., 2018). XRays or CT scan of the lumbar spine will give a definitive diagnostic. MC presents with all s/s, requires further assessment and imaging diagnostic.
2. Herniated lumbar disc – is the most common cause of lower back pain. It is caused by inflammation between the vertebrae and it can irritate the nearby nerves, resulting in pain, numbness, or weakness of the affected extremity. It can be medial or lateral, medial disc herniation has greater chance of positive outcomes post-surgical treatment (Chirchiglia et al., 2020).
3. Muscle strain – is a common work-place injury, is the second cause of disability among American adults. It is caused by damage to the muscle tissue or its attaching tendons, may occur during regular activity of daily living, or during strenuous activity at the work place such as heavy lifting. Pain can arise from multiple sites such as vertebral column, surrounding para-spinal muscles, tendons, ligaments, and fascia. Resting, NSAIDS, or steroid injections are possible treatments to relieve pain (Khalid et al., 2021).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby
Chirchiglia, D., Della Torre, A., & La Torre, D. (2020). Comparison of post surgical results in medial and lateral lumbar spine herniated discs: Own case series experience. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management, 22.
https://doi.org/10.1016/j.inat.2020.100748
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., & Lancet Low Back Pain Series Working Group (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet (London, England), 391(10137), 2368–2383.
https://doi.org/10.1016/S0140-6736(18)30489-6
Khalid Medani, Kushinga Bvute, Natasha Narayan, Cesar Reis, & Akbar Sharip. (2021). Treatment outcomes of peri-articular steroid injection for patients with work-related sacroiliac joint pain and lumbar para-spinal muscle strain. International Journal of Occupational Medicine and Environmental Health, 34(1), 111–120.
https://doi.org/10.13075/ijomeh.1896.01602
Pesonen, J., Shacklock, M., Rantanen, P., Mäki, J., Karttunen, L., Kankaanpää, M., Airaksinen, O., & Rade, M. (2021). Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion. BMC Musculoskeletal Disorders, 22(1), 303.
https://doi.org/10.1186/s12891-021-04159-y
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