SOAP NOTE

Name:  DB Date: 03/13/2017 Time: 10:33AM

  Age: 33 Sex: Female
SUBJECTIVE
CC: 

Patient received to clinic with complaints of “My lower back hurt and side hurts”
HPI:  (Use OLDCART)

Patient reports pain at lower right side of back that wraps around to her abdomen Onset started 2 days
ago patient was woken out of her sleep with stabbing pain Location- at right lower back that wraps
around to abdomen RLQ; Duration- non stop since it started; pain has gradually worsened.
Characteristics- pain that is stabbing and achy that goes from rt lower bask and wraps around to
abdomen; Aggravating factors- moving and coughing makes pain worse; Relieving Factors- Patient
states laying down helps soothes the pain but doesn’t takes the pain away Treatment- Ibuprofen 800mg q6h
with little to relief;
Medications: (list with reason for med )

Ibuprofen 800 mg q6h

PMH

Allergies:   NKDA, denies food allergies

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: none

Hospitalizations/Surgeries: Lasix surgery on bilateral eyes  2010

Family History

Patient was adopted at age 3 doesn’t know biological parents or health history
Social History

General: Born in Garden City Michigan was placed in foster care since birth due to mother having trouble
with drug use; patient adopted at 3 years of age

Marital status: Patient is engaged to boyfriend of 5 years

Living situation: Patient lives with fiancé and dog in midtown Detroit; patient adoptive parents lives near
by in Canton Michigan

Children: none; never pregnant

Occupation: Works at bookstore within Wayne State University in which she attends for a degree in
psychology

Leisure Patterns: Patient states she loves to read and does live poetry on the weekends at a local poetry
cafe

Social habits: Does smoke hookah occasionally and drink occasionally; patient denies recreational drug use

Spirituality: Patient is a Baptist; and occasionally attends morning service at New Jerusalem Temple

Nutrition: Pt states her appetite has increased owing to “stress”, craves chocolate, eats what she wants, no
special diet. Has not experienced any changes in her weight.

Sleep Patterns: States that she usually gets about 7-8 hrs of sleep every night.
ROS
General Cardiovascular

Denies weakness, fatigue, or fever. Denies any troubles with her heart, rheumatic fever, or
heart murmurs. Denies having chest pain or
discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, or edema.
Skin Respiratory

Denies rashes, dry skin or any size or color of Denies cough, sputum, hemoptysis, dyspnea,
moles. wheezing, or pleurisy.. Denies having asthma,
bronchitis, emphysema, pneumonia, or tuberculosis.
Eyes Gastrointestinal

Denies any changes in her vision. Had Lasix Denies trouble swallowing, heartburn, changes in
surgery on bil eyes in 2011 appetite, or nausea. States she has bowel movements
every day normally, Denies pain or bleeding with
defecation. Denies black or tarry stools, hemorrhoids,
constipation, or diarrhea. Denies abdominal pain, food
intolerance or excessive belching or passing gas.
Denies jaundice, live, or gallbladder trouble..
Ears Genitourinary/Gynecological

States she doesn’t have any hearing problems. Goes to the bathroom 4 or 5 times a day, Patient did
Denies tinnitus, vertigo, earaches, infection, or reveal that her lower back hurts more when she has to
discharge. Denies use of hearing aides.  urinate; however she has no urination changes or
dysuria nor hematuria

Menarche at age 14. Menses is regular and is every 28

days lasting 3-4 days with flow being the heaviest the
first day. Denies bleeding between periods. LMP:
September 4th. Denies PMS. Denies any vaginal
discharge, dyspareunia, itching, sores, lumps, or STDs.
Has had one partner in the past 5 years. Denies
exposure to HIV infection or STDs.
Nose/Mouth/Throat Musculoskeletal

 Denies hay fever, nose bleeding, or sinus trouble. Denies muscle weakness, paresthesia, loss of
Oral mucosa pink gums pink and moist without sensations, no severe or progressive neurological
sores teeth seen intact none missing with some deficit in lower extremity. Pt reports feeling lower
cavities; Throat pink and moist with uvula midline; back pain that started 2 days ago in rt flank lower back
Denies sore tongue, frequent sore throats or that wraps around to lower rt quadrant .
hoarseness. Denies having dry mouth or excessive
thirst.

Neck: Denies swollen glands, goiter, lumps, pain,

or stiffness in the neck.
Breast Neurological

Denies lumps, pain, discomfort or discharge. Denies changes in mood, attention or speech. Denies
headaches, dizziness, vertigo, fainting, seizures,
weakness, numbness, tingling, tremors or other
involuntary movements.
Heme/Lymph/Endo Psychiatric

Denies anemia, easy bruising or bleeding, and past Denies nervousness, tension, mood changes,
transfusions. Denies excessive thirst and hunger. depression, or memory changes.
Denies thyroid trouble, heat or cold intolerance,
excessive sweating, polyuria or changes in shoe
size. Denies weight changes or fever.

OBJECTIVE
Weight  120lbs      BMI 20 Temp 98 F BP 114/74
Height 67” Pulse 89 Resp 20
General Appearance

Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears
concerned w/o signs of acute distress.
Skin

Skin is warm, pink and supple, no lesions noted.

HEENT

Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM
intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no
erythema; Neck: thyroid non palpable, no carotid bruits.
Cardiovascular

Carotid upstrokes are brisk, w/o bruits. S1 louder than S2 on auscultation. No murmurs or extra sounds.
Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender.
No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial
pulses are 2+ , brisk, and symmetric.
Respiratory

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or
ronchi.
Gastrointestinal

Abdomen is flat with active bowel sounds in all four quadrants. It is soft with tenderness felt at right low
quadrant and wraps around to flank and lower back; no masses or hepatosplenomegaly.
Breast

Deferred
Genitourinary
Deferred
Musculoskeletal

Patient able to perform ROM to BUE and BLE; patient seen in pain when doing activity,
No joint deformities. Gait/Posture: Flexed forward at 15º, walked slowly with a wide based stance, and
grimaced with movement. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis;
unable to extend or rotate. Lateral movement: bilaterally to 20º.
Neurological

Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating
movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense,
vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes
down going.

Psychiatric

Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.
Lab Tests

 
Special Tests

 None ordered today.

 Diagnosis
 Diagnosis:

1. Acute lumbosacral strain (M54.5)

Differentials:
1. Acute lumbosacral pain (M54.5): Minimal discomfort initially followed by increased pain and
stiffness 12-36 hrs later, SLR, crossed SLR, heel and toe walking were intact. No muscular
weakness or loss of sensation. DTRs were equal and not depressed. Babinski negative. Spasm
noted in paravertebral muscles.
2. Herniated lumbar disc (M51.2): Pain in buttocks.
3. Sciatica (M54.3): Pain in back/buttocks.
4. Possible vertebral Fx (S32.009A): Low back pain.

Plan/Therapeutics
Plan: 

Diagnostic: No tests needed at this time

Therapeutic: Pharmacological:
D/C OTC Tylenol. Start Ibuprofen 600mg 1 po q8h x 7 days then PRN for pain. Robaxin 500mg 1 po
QAM, 2 po QHS x 2 weeks then 1 po Q8H PRN for back pain.
Non-pharmacological:
Local application of ice may help initially to decrease pain, apply cold pack for 20 minutes q2-3 hours
while awake. After 2-3 days, either heat or ice may be applied. No bed rest indicated. Take 3-7 days off
work (her job would increase stress on her back), or perform other duties until the symptoms abate.
Patient Education:
1. Avoid jerky, hurried movements when lifting
2. Lift with legs by straddling the load; bend knees to pick up load; keep back straight (do not bend
back)
3. Keep objects close to the body at navel level when lifting
4. Avoid twisting, bending, reaching while lifting
 5. Avoid prolonged sitting
6. Change positions often while sitting
7. A soft support belt for the back, armrests to support some body weight, a slight reclining chair may
make sitting more comfortable
8. Firm mattress/bed board, lying supine with hips and knees flexed on pillows is beneficial when
sleeping
9. May return to work in 4-8 days
10. As soon as she returns to regular activities (in 2 weeks), aerobic conditioning exercises such as
walking, swimming, stationary biking, or even light jogging may be recommended to avoid
debilitation.
Referral: None
Follow-Up: Come back if the pain does not improve by 50% in 24-48 hrs. Return to the office in 7-10
days. Return sooner if neurological symptoms worsen or bowel/bladder dysfunction occurs.
 Evaluation of patient encounter:

I was able to assess the patient independently and then later present the case to my preceptor by providing
her with the pertinent positive on the ROS and on the physical exam findings. I participated in the Dx
selection and in the treatment plan.

Weaknesses: I must by managing my time. It took me almost 45 minutes to work on this case.

Strengths: I have improved my physical exam skills, I feel confident and comfortable interacting with
patients on my own.

Reflection: I feel like I am improving with collecting enough information and with performing focused
physical exams. I feel like everything is starting to fall in the right place.

References:

Bickley, L. (2007). Bates’ Guide to Physical Examination & History Taking (9th Edition),

Lippincott, Williams and Wilkins Publishers

National Guideline Clearinghouse. (2008). Management of Acute Low Back Pain. Retrieved

November 10, 2008 from http://www.guideline.gov/summary/summary.aspx?

doc_id=12491&nbr=006422&string=back+AND+pain

Uphold C, Graham M. Clinical Guidelines in Family Practice. 4th ed. Gainesville, Fl: Barmarrae

Books Inc; 2003:370-376.