Episodic/Focused SOAP Note Lower Back Pain Example

Episodic/Focused SOAP Note Lower Back Pain Example with subjective, objective, assessment and a care plan.

Case Scenario 1 (Episodic/Focused SOAP Note Lower Back Pain Example)

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 who 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.

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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.

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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.

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LYMPHATICS:  denies large lymph nodes

PSYCHIATRIC:  Denies depression or anxiety, reports job being low stress

ENDOCRINOLOGIC:  Denies sweating unless in the heat, and 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 – 6’1”

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 the 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 of femoral hip stretch to detect inflammation of the nerve root at L1, L2, L3, or L4 levels. The patient is prone and asked to extend a hip; the 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). X-rays or CT scans of the lumbar spine will give a definitive diagnosis. MC presents with all s/s and requires further assessment and imaging diagnostic.

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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 a greater chance of positive outcomes post-surgical treatment (Chirchiglia et al., 2020). 

3. Muscle strain – is a common workplace injury, and is the second cause of disability among American adults. It is caused by damage to the muscle tissue or its attaching tendons and may occur during the regular activity of daily living, or during a strenuous activity at the workplace such as heavy lifting. Pain can arise from multiple sites such as the 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).

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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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