R’s 2 soap notes

SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA

CC:

"Severe low back pain from pulling bushes, radiating down my left leg."

HPI:

35-year-old male presents with acute low back pain that began suddenly during yard work pulling bushes. The pain is sharp and radiates down the posterior aspect of the left leg. He rates the pain 8/10. Pain worsens with active movement and is less intense with passive movement. He took 800 mg ibuprofen once with slight relief.

OLDCART:

· Onset: Sudden

· Location: Lower back radiating to left leg

· Duration: Acute

· Characteristics: Sharp, lightning-like

· Aggravating: Active movement

· Relieving: Passive movement, ibuprofen

· Treatment: Took 800 mg ibuprofen once

PMH:

No prior illnesses, hospitalizations, surgeries, or back injuries.

ALLERGIES

N/A

MEDICATIONS

800 mg ibuprofen PO single dose at onset of symptoms.

SH

Divorced with joint custody of three children. Ex-smoker (1 pack/day, 10 years), quit 5 years ago, now vapes daily. Has one beer with evening meal. Denies use of illicit drugs. Works in IT, sitting 8 hours/day. Runs 30 minutes/day, describes healthy eating. Seeks primary care only for an acute complaint; no routine check-up. Denies cultural or financial stressors.

FH

No history of spinal, musculoskeletal problems, or malignancy in family.

HEALTH PROMOTION & MAINTENANCE

· Immunizations: Not up to date.

· Exercise: Runs 30 minutes/day.

· Diet: Describes as “healthy,” no specifics given.

· Screenings: BP in normal range at 124/78. Counseling for vaping cessation. Alcohol consumption within low-risk category. No lipid panel or other tests reported. No eye or dental exams within last year.

ROS

(put N/A in sections not completed day of exam)

Constitutional

Denies fever, chills, or weight changes.

Head

Denies headaches.

Eyes

Denies visual changes or complaints.

Ears, Nose, Mouth, Throat

Denies hearing loss, nasal congestion, sore throat, or oral lesions.

Neck

Denies stiffness or swelling.

Cardiovascular/Peripheral Vascular

Denies chest pain or edema.

Respiratory

Denies cough or shortness of breath.

Breast

Denies tenderness or masses reported.

Gastrointestinal

Denies bowel control loss, nausea, or vomiting.

Genitourinary

Denies bladder control loss or dysuria.

Musculoskeletal

Low back pain radiating to left leg; positive straight leg raise.

Integumentary

Denies rashes or bruising.

Neurological

Positive straight leg raise; no numbness, deficits, or saddle anesthesia.

Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)

Denies anxiety, depression, or mood changes reported.

Endocrine

Denies polyuria, polydipsia, or temperature intolerance.

Hematologic/Lymphatic

Denies bleeding or lymph node swelling.

Allergic/Immunologic

Denies allergies or immune-related symptoms.

Other

N/A

O: OBJECTIVE DATA

VITALS:

HR: 79

RR: 16

BP: 124/78

Temp: 97.3°F

SpO2%: 100%

Ht: N/A

Wt: N/A

BMI: N/A

Age: 35

LMP: N/A

PAIN: 8/10, sharp

PHYSICAL EXAM

General Appearance

In acute distress due to pain.

Head

Normocephalic, atraumatic.

Eyes

PERRLA, no discharge or redness.

ENT, Mouth

Moist mucous membranes, no lesions.

Neck

Supple, no masses or tenderness.

Cardiovascular/Peripheral Vascular

RRR, no murmurs, no peripheral edema.

Respiratory

Clear to auscultation bilaterally.

Breast

No abnormalities noted (not examined in detail).

Gastrointestinal

Abdomen soft, non-tender, no distension.

Genitourinary Male

· External Exam

Deferred.

· Internal Exam

N/A

Genitourinary Female

· External Exam

N/A

· Internal Exam

N/A

Musculoskeletal

Severe pain with active movement; less with passive. Positive straight leg raise on the left.

Integumentary

Intact skin, no rashes or bruises.

Neurological

Alert and oriented x3. Positive left straight leg raise; no motor or sensory deficits, no saddle anesthesia.

Psychiatric

Alert, appropriate affect and mood.

Endocrine

No thyroid enlargement or skin changes noted.

Hematologic/Lymphatic

No bruising, petechiae, or lymphadenopathy.

Allergic/Immunologic

No signs of allergic reaction.

Other

N/A

A: ASSESSMENT AND DIAGNOSIS

DIAGNOSIS

ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Acute low back pain with sciatica

M54.41

2. Possible lumbar disc herniation

M51.26

3. Musculoskeletal strain

M54.9

VISIT CODES

CPT BILLING CODES

99203

DIAGNOSTICS

POC TESTING

N/A

TESTS REVIEWED

N/A

P: PLAN

ACTIONS

1.

Diagnosis: Acute low back pain with sciatica

· Diagnostics Order: Lumbar X-ray; MRI if symptoms persist.

· Therapeutic: Ibuprofen 600 mg PO q6-8h PRN, #30, 1 refill; Cyclobenzaprine 10 mg PO qhs PRN, #10, no refills.

· Education: Teach proper body mechanics; advise to avoid heavy lifting. Recommend heat/ice therapy and light physical activity. Discuss symptoms of sciatica and red flags such as bowel/bladder loss.

· Consultation/Collaboration: Refer to physical therapy if no improvement in 1-2 weeks.

2.

Diagnosis: Possible lumbar disc herniation

· Diagnostics Order: MRI if symptoms do not improve.

· Therapeutic: Continue current medications.

· Education: Explain the condition and warning signs of cauda equina syndrome.

· Consultation/Collaboration: Refer to neurosurgery if neurological deficits develop.

3.

Diagnosis: Musculoskeletal strain

· Diagnostics Order: None

· Therapeutic: Continue with existing treatment plan.

· Education: Reinforce use of proper body mechanics and encourage gradual return to full activity.

· Consultation/Collaboration: Refer to physical therapy if necessary.

PREVENTITIVE

· Tobacco: Counsel on vaping cessation (USPSTF).

· Screenings: Recommend lipid panel and BP screening with primary physician.

· Immunizations: Update influenza vaccination and Tdap.

· Lifestyle: Encourage ongoing exercise and healthy diet once recovered. Recommend dental and vision exams.

FOLLOW UP

Re-assess pain in 1-2 weeks, check for response to treatment, and review imaging findings. Report immediately if worse or red flags emerge such as bowel/bladder incontinence or saddle anesthesia. If not getting better, order MRI and refer to PT or specialist referral.