Roch week 4 soap

SOAP Note _______ NU___:_________ Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA CC: "My lower back has been hurting for the past two weeks, especially after

long hours at my desk job. I’ve also noticed stiffness in the mornings."

HPI: • O: Gradual onset ~2 weeks ago • L: Bilateral lower back • D: Constant ache, worse by end of day • C: Dull, achy pain • A: Prolonged sitting, lifting heavy objects • R: Heat, stretching, ibuprofen • T: OTC meds, no PT • S: 32F with lower back pain, likely musculoskeletal

PMH: • Hypertension (controlled, on lisinopril 10mg daily) • Tonsillectomy at age 12 • No hospitalizations.

ALLERGIES NKDA

MEDICATIONS • Lisinopril 10mg PO daily (for HTN) • Ibuprofen 400mg PO PRN (for pain)

SH • Occupation: Accountant (sedentary job) • Non-smoker • Occasional alcohol use • Exercises 2x/week (yoga, walking) • High work-related stress • No drug use, low HIV risk • Sexually active; no reported issues • Moderate caffeine intake likely (desk job)

FH • Maternal: HTN diagnosed at 50, osteoporosis at 65 • Paternal: Type 2 diabetes diagnosed at 55

HEALTH PROMOTION & MAINTENANCE

• Immunizations: Flu (2023), COVID-19 booster (2023) • Diet: Balanced, low sodium • Exercise: Yoga and walking 2x/week • Dental: Last exam 6 months ago • Vision: Eye exam overdue (none in 2+ years) • Plans for DEXA by age 40

SOAP Note _______ NU___:_________ Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Constitutional No fever, chills, or fatigue Head No headaches, trauma, or dizziness Eyes No vision changes, eye pain, or

discharge Ears, Nose, Mouth, Throat No congestion, sore throat, or ear

symptoms Neck No stiffness or swelling Cardiovascular/Peripheral Vascular

No chest pain, palpitations, or edema

Respiratory Denies coughing, SOB, or wheezing Breast No lumps or discharge reported Gastrointestinal No nausea, vomiting, or bowel changes Genitourinary No dysuria, urgency, or incontinence Musculoskeletal Reports dull lower back pain, no joint

swelling Integumentary Denies having rashes, bruising, or

wounds Neurological No numbness, tingling, or headaches Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)

Feels stressed from work; no depression or anxiety noted

Endocrine No polydipsia, polyuria, or heat/cold intolerance

Hematologic/Lymphatic No easy bruising, bleeding, or swollen nodes

ROS

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

Allergic/Immunologic No known allergies or immune disorders

Other Denies weight changes or urinary symptoms

O: OBJECTIVE DATA HR: 72 RR: 16 BP: 118/78 Temp: 98.4°F

SpO2%: 98% Ht: 5'6" Wt: 150 lbs BMI: 24.2

VITALS:

Age: 32 LMP: N/A PAIN: Reports 4/10 dull lower back pain

General Appearance Alert, well-nourished, in no acute distress

SOAP Note _______ NU___:_________ Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Head Normocephalic, atraumatic Eyes PERRLA, no conjunctival injection ENT, Mouth Moist mucosa, no erythema or

lesions Neck Supple, no lymphadenopathy or

thyromegaly Cardiovascular/Peripheral Vascular Regular rate and rhythm, no

murmurs, pulses intact Respiratory Clear to auscultation bilaterally, no

rales/wheezes Breast N/A Gastrointestinal Soft, non-tender, no

hepatosplenomegaly Genitourinary Male

• External Exam N/A • Internal Exam N/A

Genitourinary Female • External Exam No GU complaints • Internal Exam Deferred

Musculoskeletal Tender lumbar paraspinals, stiff flexion, normal ROM, no swelling

Integumentary Skin intact, no lesions or rashes Neurological Alert, oriented, normal strength

and sensation; negative straight-leg raise

Psychiatric Appropriate affect; good insight and judgment

Endocrine No signs of hormonal imbalance Hematologic/Lymphatic No lymphadenopathy, no bruising

PHYSICAL EXAM

(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)

Allergic/Immunologic No signs of allergic reaction Other N/A

A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES

1. Low back pain (musculoskeletal) M54.5PRIORITIZE DIAGNOSIS

2. Hypertension, controlled I10

SOAP Note _______ NU___:_________ Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

3. Health maintenance (osteoporosis risk) Z79.899

VISIT CODES CPT BILLING CODES 99213 (Established patient, low- moderate complexity)

POC TESTING None required. No tests today; imaging if symptoms persist or worsen

DIAGNOSTICS

TESTS REVIEWED N/A

P: PLAN 1. Diagnosis: Low back pain

Diagnostics Order: Consider lumbar spine X-ray if pain persists beyond 4 weeks or worsens

Therapeutic: Naproxen 220mg PO BID PRN, continue stretching and ergonomic adjustments at workstation

Education: Educated on posture, body mechanics, daily stretches; avoid heavy lifting

Consultation/Collaboration: Refer to physical therapy if no improvement in 4 weeks.

ACTIONS

2. Diagnosis: Hypertension

Diagnostics Order: Routine BP monitoring every 3–6 months; annual CMP to monitor kidney function and electrolytes due to lisinopril use.

Therapeutic: Continue lisinopril 10mg PO daily

Education: Reinforced adherence to low-sodium diet, encouraged home BP monitoring

Consultation/Collaboration: No referral needed currently. May consider referral to cardiology if BP control worsens or signs of target organ damage arise.

SOAP Note _______ NU___:_________ Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

3. Diagnosis: Health maintenance

Diagnostics Order: Schedule DEXA scan by age 40

Therapeutic: Encourage daily calcium (1000mg) and vitamin D (800 IU) intake through diet or supplements to reduce osteoporosis risk.

Education: Recommend eye exam within 6 months; discussed importance of maintaining routine health screenings and dental exams.

Consultation/Collaboration: May consider future referral to ophthalmology if vision changes occur or if eye exam reveals abnormalities

PREVENTITIVE

(Used for comprehensive exams)

• Eye exam recommended • DEXA scan by age 40 • Re-evaluation of back pain in 4 weeks • Annual wellness visits scheduling

FOLLOW UP Follow-up in 4 weeks to reassess back pain and evaluate if PT or imaging is needed