| Assessing Musculoskeletal Pain |
Episodic/Focused SOAP Note
Patient Information:
T G, 42, Female, Caucasian
S.
Chief Complaint (CC): Lower back pain.
Tim Goode is a 42-year-old Caucasian male with a past medical history of hypertension, GERD, hyperlipidemia, Type 2 diabetes, and obesity who presented to the clinic with a complain lower back pain for a month that radiates to his left leg. He also complains of numbness and tingling to his left leg down to his foot. He stated that the pain level is at 6/10 especially when walking, or sitting, but resides when laying down. He has been using over- the-counter Ibuprofen 200mg as needed, extra strength acetaminophen 1000 mg as needed and applies ice pack to his lower back to relieve the pain. No nausea or vomiting. Patient denies chest pain or palpitation. No shortness of breath.
Medications:
Lisinopril 20 mg Daily
Atorvastatin 20 mg QHS
Ibuprofen 200 mg Q6hr. As Need
Metformin 500 mg BID
Acetaminophen 1000mg Q6Hr, PRN
Allergies:
Penicillin- Hives
Past Medical History (PMH):
Hypertension
Hyperlipidemia
Obesity
Type 2 diabetes
GERD
Past Surgical History (PSH):
Distal radius fracture at age 13- Open Reduction internal fixation
Sexual/Reproductive History:
Single
Sexually active
No history of STD
Personal/Social History:
Denies illicit drug use
Denies tobacco
Drinks a glass of wine with dinner
Immunization History:
Tdap 2/23/2019
Flu 8/19/2021
COVID vaccine Pfizer- 1st dose 10/1/2020-2nd dose 11/2/2020
Family History:
Mother- Alive, 77 yrs. old Stage 2 breast cancer, hypertension, obesity.
Father- Alive, 79 yrs. old, obesity, hypertension, and type 2 diabetes.
Brother- Alive, 40 yrs. old, past medical history of hyperlipidemia.
Sister- Deceased at age 20 due to motor vehicle accident.
Paternal Grandmother- Alive, 95 yrs. old, history of hypertension, type 2 diabetes.
Paternal Grandfather- Deceased at age 89 due to heart attack.
Review of Systems:
General: No recent wright loss or gain. Denies fever, chills, and cough.
Cardiovascular/Peripheral Vascular: Denies chest pain or palpitations.
Respiratory: No difficulty breathing.
Gastrointestinal: Denies nausea, vomiting, constipation or diarrhea.
Musculoskeletal: Reports lower back pain that radiates to the right leg
Psychiatric: Denies anxiety or depression.
Neurological: No headache. Tingling, or numbness to the right leg and foot
OBJECTIVE DATA
Physical Exam:
Vital signs:
BP- 145/73
Pulse-89 bpm
Temperature- 98.7
Respiratory rate- 18
O2-99% on room air
WT: 202 lbs.
HT: 6’0
General: The patient appears to be claim, relaxed, and well groomed. No pain or discomfort noted at this time. Alert and oriented to person, place, time, and situation. All questions and concerns were answered and addressed.
Cardiovascular/Peripheral Vascular: S1, & S2 noted. No gallop, or friction rub sound. Pulses are palpable 2+ in all four extremities. No JVD or edema. Capillary refill time less than 2 seconds.
Respiratory: Lung sounds are clear in all four lobes. No stridor or respiratory distress noted.
Gastrointestinal: Abdomen is soft, and round, no mass, no tenderness. Negative for rebound tenderness or guarding.
Musculoskeletal: Positive straight leg test. Normal gait. No kyphosis or scoliosis noted.
Neurological: PERRAL, equal hand grasp, reflexes are normal, no cranial nerve deficits. Tenderness and pain to lower back that radiates to the left leg
Skin: Warm, dry, and intact. Negative for rash, pallor, diaphoresis, or erythema
Start here
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.
ASSESSMENT: Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Episodic/Focused SOAP Note
Patient Information:
T G, 42, Female, Caucasian
S.
Chief Complaint (CC): Lower back pain.
Tim Goode is a 42-year-old Caucasian male with a past medical history of hypertension, GERD, hyperlipidemia, Type 2 diabetes, and obesity who presented to the clinic with a complain lower back pain for a month that radiates to his left leg. He also complains of numbness and tingling to his left leg down to his foot. He stated that the pain level is at 6/10 especially when walking, or sitting, but resides when laying down. He has been using over- the-counter Ibuprofen 200mg as needed, extra strength acetaminophen 1000 mg as needed and applies ice pack to his lower back to relieve the pain. No nausea or vomiting. Patient denies chest pain or palpitation. No shortness of breath.
Medications:
Lisinopril 20 mg Daily
Atorvastatin 20 mg QHS
Ibuprofen 200 mg Q6hr. As Need
Metformin 500 mg BID
Acetaminophen 1000mg Q6Hr, PRN
Allergies:
Penicillin- Hives
Past Medical History (PMH):
Hypertension
Hyperlipidemia
Obesity
Type 2 diabetes
GERD
Past Surgical History (PSH):
Distal radius fracture at age 13- Open Reduction internal fixation
Sexual/Reproductive History:
Single
Sexually active
No history of STD
Personal/Social History:
Denies illicit drug use
Denies tobacco
Drinks a glass of wine with dinner
Immunization History:
Tdap 2/23/2019
Flu 8/19/2021
COVID vaccine Pfizer- 1st dose 10/1/2020-2nd dose 11/2/2020
Family History:
Mother- Alive, 77 yrs. old Stage 2 breast cancer, hypertension, obesity.
Father- Alive, 79 yrs. old, obesity, hypertension, and type 2 diabetes.
Brother- Alive, 40 yrs. old, past medical history of hyperlipidemia.
Sister- Deceased at age 20 due to motor vehicle accident.
Paternal Grandmother- Alive, 95 yrs. old, history of hypertension, type 2 diabetes.
Paternal Grandfather- Deceased at age 89 due to heart attack.
Review of Systems:
General: No recent wright loss or gain. Denies fever, chills, and cough.
Cardiovascular/Peripheral Vascular: Denies chest pain or palpitations.
Respiratory: No difficulty breathing.
Gastrointestinal: Denies nausea, vomiting, constipation or diarrhea.
Musculoskeletal: Reports lower back pain that radiates to the right leg
Psychiatric: Denies anxiety or depression.
Neurological: No headache. Tingling, or numbness to the right leg and foot
OBJECTIVE DATA
Physical Exam:
Vital signs:
BP- 145/73
Pulse-89 bpm
Temperature- 98.7
Respiratory rate- 18
O2-99% on room air
WT: 202 lbs.
HT: 6’0
General: The patient appears to be claim, relaxed, and well groomed. No pain or discomfort noted at this time. Alert and oriented to person, place, time, and situation. All questions and concerns were answered and addressed.
Cardiovascular/Peripheral Vascular: S1, & S2 noted. No gallop, or friction rub sound. Pulses are palpable 2+ in all four extremities. No JVD or edema. Capillary refill time less than 2 seconds.
Respiratory: Lung sounds are clear in all four lobes. No stridor or respiratory distress noted.
Gastrointestinal: Abdomen is soft, and round, no mass, no tenderness. Negative for rebound tenderness or guarding.
Musculoskeletal: Positive straight leg test. Normal gait. No kyphosis or scoliosis noted.
Neurological: PERRAL, equal hand grasp, reflexes are normal, no cranial nerve deficits. Tenderness and pain to lower back that radiates to the left leg
Skin: Warm, dry, and intact. Negative for rash, pallor, diaphoresis, or erythema
Start here
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Accurate diagnosis of lower back pain should start by identifying the possible nerve routes that might be involved in the pain. In the given scenario, the nerve roots that might be involved in the patient’s pain are nerve L4 and S1. Nerve L4 is part of the nerves that form the lumbar plexus and S1 is part of the nerves that form the lumbosacral plexus (Andrade et al., 2019). To test for nerve L4, the clinician should perform resisted dorsiflexion of the ankle whereas the best way to test for nerve S1 is to resisted plantar flexion of the ankle (Andrade et al., 2019).
The healthcare provider should explore numerous symptoms that might occur together with the lower back pain. In addition to the symptoms that have already been captured, the additional symptoms that should be explored include; whether the pain improves with rest, the difference in pain severity at the lower back and leg, and whether there is weight loss, fever, abdominal discomfort, nausea, and vomiting. It is important to find out whether the patient has these symptoms because lower back pain can be attributed to spine-related issues, systemic issues, and referred pain (American Academy of Family Physicians, 2020). The differential diagnoses for the patient’s pain are selected based on the possible origins of the condition.
The Agency for Healthcare Research and Quality (AHRQ) guidelines outline frameworks that are used to make a diagnosis. One of these frameworks is the use of clinical practice guidelines (Agency for Healthcare Research and Quality, 2018). Based on the American Academy of Family Physicians guidelines for the diagnosis and treatment of low back pain, the possible origins or differential diagnoses for the patient’s pain include; herniated nucleus pulposus, lumbar strain/sprain, spinal stenosis, spondylolisthesis, or spondylolyis (American Academy of Family Physicians, 2020).
Physical examination to be performed should comprise of musculoskeletal and neurological assessment. Special maneuvers that will be performed should aim to find any issues with these two systems. They include; performing the Flexion, Abduction, and External Rotation (FABER) test to detect hip or sacro-iliac joint issues, palpation of the spines and joints to detect tenderness and pain, inspecting the spine for deformities, performing straight raise leg test to detect nerve root involvement in the patient’s pain, performing a reverse straight raise leg test, and assessing proximal and distal sharp/dull pain sensation of the legs (Amerian Academy of Family Physicians, 2020).
Diagnostic Test/Labs:
A straight leg raise test: This test is positive for L4-S1 nerve root pain if it radiates below the knee. These findings confirm herniated nucleus pulposus (American Academy of Family Physicians, 2020).
Magnetic Resonance Imaging or a Computed tomography (CT) scan: These tests help to detect musculoskeletal issues (Traeger et al., 2017).
Complete Blood Count (CBC): It helps to identify whether the lower back pain is due to infections of the spine (American Academy of Family Physicians, 2020).
ASSESSMENT:
Herniated nucleus pulposus: Low back pain in herniated nucleus pulposus that is attributed to L4-S1 nerves normally radiated to the legs. It worsens with walking and standing (American Academy of Family Physicians, 2020).
Lumbar strain/sprain: This condition is associated with diffuse lower back pain that worsens with walking/movement (American Academy of Family Physicians, 2020).
Spinal stenosis: Lower back pain worsens with walking and standing. The pain radiates to the leg (American Academy of Family Physicians, 2020).
Spondylolisthesis: Unilateral or bilateral pain on the lower back that radiates to the legs. It worsens with walking and standing (American Academy of Family Physicians, 2020).
Spondylolyis: This condition causes lower back pain that worsens with activity and spine extension (American Academy of Family Physicians, 2020).
References
Agency for Healthcare Research and Quality. (2018). Clinical practice guidelines archive. https://www.ahrq.gov/prevention/guidelines/archive.html
American Academy of Family Physicians. (2020). Diagnosis and treatment of acute low back pain. https://www.aafp.org/afp/2012/0215/p343.html
Andrade, M. J., & Soares, T. F. (2019). The importance of the clinical examination of the lower sacral segments: Four case reports. The Journal of Spinal Cord Medicine, 42(1), 123–127. https://doi.org/10.1080/10790268.2018.1432306
Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Diagnosis and management of low-back pain in primary care. CMAJ: Canadian Medical Association Journal = journal de l’Association Medicale Canadienne, 189(45), E1386–E1395. https://doi.org/10.1503/cmaj.170527