Episodic/Focused SOAP Note
Patient Information:
J S, 42, Male, Caucasian.
Subjective.
CC (chief complaint)> Lower back pain
HPI: John Smith is a 42-year-old male patient with a history of Hypertension, type-2-diabetes, arthritis, and general anxiety disorder came to the clinic with a complain of lower back pain for the past month. He reports that the pain sometimes radiates to his left leg. He denies any recent fall. He rated the pain level to 5/10. He reported the pain started when he woke up, but usually come and goes. The pain is associated with tingling and numbness to his left leg. Walking, sitting, and standing makes the pain worse, but relieve with taking over the counter Ibuprofen 200 mg as needed, laying down and ice pack for the pain. He denied nausea or vomiting. No chest pain or dizziness reported.
Current Medications:
Amlodipine 10 mg BID
Metformin 500 mg BID
Lorazepam 0.5 mg TID PRN
Ibuprofen 200 mg Q4 hours, PRN
Allergies: NKA
PMHx:
Hypertension
General anxiety disorder
Influenza current this season
Tdap March 2018
Appendectomy age 15
Up to date in all medications
Social Hx:
Patient is married with 3 children. He currently works at Walmart store warehouse and a part time coach for soccer team. He denies any tobacco use, cigarette use, and no illicit drug use. He drink alcohol occasionally and play soccer with his friends every weekends. He had his last annual exam 2 months ago and takes care of his health. He leaves at home with wife and 2 of his kids and uses smart fire detectors. He also uses seatbelts and doesn’t text while driving. He has a good support system at home.
Family Hx:
Father: 79 and alive with hypertension, hyperlipidemia, stroke and BPH
Mother: 75 and alive with hypertension, DM2, right breast cancer with mastectomy
Brother: 44 and alive with hypertension
Sister: 49 alive with breast cancer and DM2
Sister: 40 alive with no know medical history
Paternal grandparent: both dead from motor vehicle accident with unknown medical histories
Maternal grandparents: Both alive with dementia and high cholesterol.
Review of system:
GENERAL: No recent weigh loss or gain. Denies fever, chills, or weakness.
CARDIOVASCULAR: No chest pain or palpitation.
RESPIRATORY: No Shortness of breath or cough.
MUSCULOSKELETAL: Pain on the lower back and radiates to left leg. Tingling and numbness to the left leg. Denies history of arthritis, gout or falls.
SKIN: No rash or redness
NEUROLOGICAL: No headache, syncope, or dizziness. Reports numbness or tingling to his left leg. No change in bowel or bladder control.
PSYCHIATRIC: History of anxiety. No suicidal ideation noted
Objective.
Physical examination:
Vital Signs- BP 139/88, P 70, T 98.1 orally; RR 18 non-labored; Wt: 180 lbs; Ht: 5’10”
GENERAL: Patient is alert and oriented to self, place, time, year, and situation. Appeals discomfort due lower back pain. Appropriately dressed and well groomed.
CARDIOVASCULAR: Regular heart rhythm. (S1, S2), no rub or gallop. No JVD, or carotid bruits appreciated.
RESPIRATORY: Symmetrical chest expansion, clear bilateral breath sound. No wheezing or coarse noted
MUSCULOSKELETAL: Spine well aligned; no scoliosis or kyphosis noted. No mass or nodule noted on palpation. Full range of motion in all extremities. No crepitation noted with movement. Cervical spine concave with head in appropriate position Thoracis and lumber spine convex. Knees and feet are well aligned. Bear weight in all extremities. No foot drop noted. Toes are straight, flat to the floor and align to each other.
NEUROLOGICAL: Positive numbness and tingling to the right leg.
SKIN: Cap refill < 3 seconds and normal skin turgor in all fingers and toes
STARTS 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 results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
- MRI Lower back
- CT scan
- CBC and BMP blood test
Assessment.
- Differential Diagnoses. Identify at least fivepossible conditions that may be considered in a differential diagnosis for the patient. For each diagnosis, provide supportive documentation with evidence-based guidelines.
References
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
Episodic/Focused SOAP Note
Patient Information:
J S, 42, Male, Caucasian.
Subjective.
CC (chief complaint)> Lower back pain
HPI: John Smith is a 42-year-old male patient with a history of Hypertension, type-2-diabetes, arthritis, and general anxiety disorder came to the clinic with a complain of lower back pain for the past month. He reports that the pain sometimes radiates to his left leg. He denies any recent fall. He rated the pain level to 5/10. He reported the pain started when he woke up, but usually come and goes. The pain is associated with tingling and numbness to his left leg. Walking, sitting, and standing makes the pain worse, but relieve with taking over the counter Ibuprofen 200 mg as needed, laying down and ice pack for the pain. He denied nausea or vomiting. No chest pain or dizziness reported.
Current Medications:
Amlodipine 10 mg BID
Metformin 500 mg BID
Lorazepam 0.5 mg TID PRN
Ibuprofen 200 mg Q4 hours, PRN
Allergies: NKA
PMHx:
Hypertension
General anxiety disorder
Influenza current this season
Tdap March 2018
Appendectomy age 15
Up to date in all medications
Social Hx:
Patient is married with 3 children. He currently works at Walmart store warehouse and a part time coach for soccer team. He denies any tobacco use, cigarette use, and no illicit drug use. He drink alcohol occasionally and play soccer with his friends every weekends. He had his last annual exam 2 months ago and takes care of his health. He leaves at home with wife and 2 of his kids and uses smart fire detectors. He also uses seatbelts and doesn’t text while driving. He has a good support system at home.
Family Hx:
Father: 79 and alive with hypertension, hyperlipidemia, stroke and BPH
Mother: 75 and alive with hypertension, DM2, right breast cancer with mastectomy
Brother: 44 and alive with hypertension
Sister: 49 alive with breast cancer and DM2
Sister: 40 alive with no know medical history
Paternal grandparent: both dead from motor vehicle accident with unknown medical histories
Maternal grandparents: Both alive with dementia and high cholesterol.
Review of system:
GENERAL: No recent weigh loss or gain. Denies fever, chills, or weakness.
CARDIOVASCULAR: No chest pain or palpitation.
RESPIRATORY: No Shortness of breath or cough.
MUSCULOSKELETAL: Pain on the lower back and radiates to left leg. Tingling and numbness to the left leg. Denies history of arthritis, gout or falls.
SKIN: No rash or redness
NEUROLOGICAL: No headache, syncope, or dizziness. Reports numbness or tingling to his left leg. No change in bowel or bladder control.
PSYCHIATRIC: History of anxiety. No suicidal ideation noted
Objective.
Physical examination:
Vital Signs- BP 139/88, P 70, T 98.1 orally; RR 18 non-labored; Wt: 180 lbs; Ht: 5’10”
GENERAL: Patient is alert and oriented to self, place, time, year, and situation. Appeals discomfort due lower back pain. Appropriately dressed and well groomed.
CARDIOVASCULAR: Regular heart rhythm. (S1, S2), no rub or gallop. No JVD, or carotid bruits appreciated.
RESPIRATORY: Symmetrical chest expansion, clear bilateral breath sound. No wheezing or coarse noted
MUSCULOSKELETAL: Spine well aligned; no scoliosis or kyphosis noted. No mass or nodule noted on palpation. Full range of motion in all extremities. No crepitation noted with movement. Cervical spine concave with head in appropriate position Thoracis and lumber spine convex. Knees and feet are well aligned. Bear weight in all extremities. No foot drop noted. Toes are straight, flat to the floor and align to each other.
NEUROLOGICAL: Positive numbness and tingling to the right leg.
SKIN: Cap refill < 3 seconds and normal skin turgor in all fingers and toes
STARTS 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?
J.S. presents with lower back pain that sometimes radiates to his left leg. The nerve root that might be involved is the sciatic nerves from a herniated disc. Spinal nerves S3 and L4 are the sciatic nerves. They originate from the back through the pelvis then run down the leg from behind. To test for spinal nerve S3, the healthcare professional should obtain sensation scores for light touch and pain (Battistuzzo et al., 2016). The straight leg raise test is used to test for nerve L4 (Cameron, 2021). Additional symptoms that need to be explored include; whether the pain is more severe in the back than in the legs, changes in gait, whether the left leg is weak or not, and diminished joint movement (Battistuzzo et al., 2016). Using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework, the possible origin of the patient’s acute back pain or differential diagnoses include; Acute sciatic pain, spinal disc stenosis, spondylosis, myofascial pain, and osteomyelitis of the spine (Agency for Healthcare Research and Quality, 2018).
The physical examinations to be performed should be those that evaluate the neurological system and the musculoskeletal system. A number of special maneuvers should be performed to aid in identifying the neurological and musculoskeletal issues associated with the patient’s pain. For example, asking the pain to extend the spine while standing will help to evaluate the severity of the pain when there is movement of the spine. Additional maneuvers include; performing straight leg raise test to evaluate nerve roots A1, L5, and L4, performing resisted dorsiflexion of the ankle to rest nerve root L4, and obtaining motor and sensory scores (for both pain and light touch) for S3 nerve after applying deep pressure on the spine and at the back of the left leg (Andrade & Soares, 2019).
Diagnostic tests:
- MRI Lower back
- CT scan
- CBC and BMP blood test
Magnetic resonance imaging (MRI) of the lower back is necessary to be able to identify and specific nerves that are involved in the patient’s pain. A computed tomography (CT) should be performed as a confirmatory test to the possibility of obtaining false-positive results with other tests (Traeger et al., 2017). Low back pain may also occur as a result of infection of the spine. Such infections normally cause changes in the concentrations of blood cells. Therefore, it is important to perform a complete blood count (CBC) and basic metabolic panel (BMP) to evaluate variations in blood cells and electrolyte levels. These guidelines are documented in the 2017 clinical practice guideline from the American College of Physicians (Traeger et al., 2017). It is important to combine radiography tests with blood tests for more accurate diagnosis.
Assessment.
- Differential Diagnoses.
Acute sciatic pain (primary diagnosis): Low back pain that radiates to the leg is commonly associated with sciatica. The condition is referred to as acute sciatic pain when symptoms have lasted for less than two months. The nerve roots that are involved in acute sciatic pain are L4-S3. Acute sciatic pain is associated with tingling and numbness of the affected leg and the pain is worsened by walking, sitting, and standing (Styles et al., 2018). Radiographic results reveal a herniated disc.
Spinal disc stenosis: Spinal disc stenosis normally causes lower back pain that radiates to the lower limbs. The pain is worsened by walking, sitting, and standing (Cameron, 2021).
Spondylosis: Spondylosis due to degenerative disc usually causes lower back pain. The pain may radiate to the legs. Standing, walking, or sitting worsens the pain (Traeger et al., 2017).
Myofascial pain: Myofascial pain is a type of localized pain that is also characterized by tenderness of the affected spot. The pain may radiate to other areas of the body but it is normally restricted to peripheral nerves (Traeger et al., 2017).
Osteomyelitis of the spine: Infections of the bones of the spine normally cause pain on the lower back (Andrade et al., 2019).
References
Agency for Healthcare Research and Quality. (2018). Clinical practice guidelines archive. https://www.ahrq.gov/prevention/guidelines/archive.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
Battistuzzo, C. R., Smith, K., Skeers, P., Armstrong, A., Clark, J., Agostinello, J., Cox, S., Bernard, S., Freeman, B. J., Dunlop, S. A., & Batchelor, P. E. (2016). Early rapid neurological assessment for acute spinal cord injury trials. Journal of Neurotrauma, 33(21):1936-1945. doi: 10.1089/neu.2015.4360. Epub 2016 May 16. PMID: 27091217.
Cameron, G. (2021). The assessment of lower back pain in primary care
or family practice. www.jointenterprise.co.uk/backpain-1.htm
Stynes, S., Konstantinou, K., Ogollah, R., Hay, E. M., & Dunn, K. M. (2018) Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PLoS ONE 13(4): e0191852. https://doi.org/10.1371/journal.pone.0191852
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.1705