Main Post: Case 1: Back Pain

Episodic/Focused SOAP Note Template

Patient Information: Initials: A.B. Age: 42 Sex: Male Race: Caucasian

S.

CC: “I have been having lower back for the past month that sometimes radiates to my left leg.”

HPI: A.B. is a 42-year-old Caucasian male that presents to the clinic today with complaints of lower back
pain with intermittent periods of aching and shooting pain that occasionally radiates to his posterior left
leg. He reports falling from his bicycle last month on a gravel road. He reports going to urgent care the
day of his fall and they did not find anything abnormal on his x-ray images. He rates his pain as a 6 on a
pain scale of 1-10. He reports that his pain worsens when bending over or twisting his back as well as in
a sitting position. He takes and over-the-counter pain relief such as Tylenol daily and on as needed basis.
He also reports that his lower back pain is relieved when he lays supine with 2 pillows under his knees.

Current Medications:

Acetaminophen 500 mg by mouth every 6 hours as needed for pain, OTC.

Amlodipine 10 mg by mouth daily for hypertension.

Men’s Multivitamin Tablet by mouth once daily, supplement, OTC.

Omega-3 Fish Oil 1000 mg by mouth once daily, supplement, OTC.

Allergies: No known medication allergy, no known food allergy, no known environmental allergy, no
known seasonal allergies, no known latex allergy.

PMHx: Hypertension diagnosed 3 years ago. No past hospitalizations. Recent Urgent Care visit was one
month ago after his fall. No past surgeries. Up to date will all immunization. Flu shot completed this year
10/10/23. Last tetanus shot was in 2018, received from his work

Soc Hx: Patient is employed at Microsoft as a software engineer since 2008. His hobbies include cycling
with his friends once a month. He goes to the gym twice a week with his son. He has been married to his
wife for 15 years and has a 14-year-old son that is in high school. He lives in a one-story house with his
wife, mother, son, and 2 cats. He also has an older brother that lives 2 hours away from him. He denied
ever smoking tobacco and vaping. He denied using illicit drugs. He reports consuming 2-4 cups of beer
once a month when he goes out with his cycling friends. He drives a car and always wears a seatbelt. He
states he always wear a helmet when goes biking. He reports he has working smoke detectors in his
one-story house. He uses his cellphone for 3-4 hours a day and denied using his cellphone while driving.
At work he has his laptop and computer that he uses for 8 hours. He reports having a good support
system with his family and friends.

Fam Hx:

Spouse, 42, has diabetes type 2 and hypertension.

Son, 14, no known medical issues.

Father, 66, deceased, myocardial infarction

Mother, 68, has hypertension, spinal stenosis and arthritis.

Paternal Grandmother, 82, deceased, Alzheimer’s disease.

Paternal Grandfather, 85, deceased, stroke.

Maternal Grandmother, 80, has type 2 diabetes and hypertension.

Maternal Grandfather, 60, deceased, colon cancer.

Brother, 45, has hypertension and type 2 diabetes.

ROS:

GENERAL: No weight loss and weight gain, fever, chills, weakness, or fatigue.

HEENT: Head: No headaches. Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: No burning on urination or discomfort. No hematuria.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the

extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Reports lower back pain that occasionally radiates to his posterior left leg. No joint
stiffness.

LYMPHATIC: No enlarged lymph nodes and no palpable lymph nodes.

O.

Physical exam:

Vital Signs: Height: 5’10” Weight: 180 lbs BMI: 25.8; BP sitting left arm: 132/78; Pulse: 90; Respirations:
18; O2 Saturation: 97% on RA; Temp: 98.2 F

General: 42-year-old Caucasian male sitting upright on the exam table with no acute distress. He is alert
and oriented to person, place, and time. Speech is clear.

Cardiovascular/Peripheral Vascular: S1, S2 auscultated regular rhythm. No S3 and S4 sounds

auscultated. No murmur upon auscultation. Denied chest pains or palpitations. +2 dorsalis pedis, +2
posterior tibial, and +2 radial pulses. Femoral and brachial pulses are equal, and no abdominal bruit
auscultated. No edema noted.

Respiratory: Respirations are equal and non-labored. Clear to auscultations on all lobes.
Gastrointestinal: Last bowel movement was last night. No diarrhea, no constipation, no nausea, and no
vomiting. Continent with no change in bowel patterns. Abdomen is soft and non-tender to palpitation
and percussion.

Musculoskeletal: Lower back pain 6/10, radiates occasionally to the left posterior leg. Pain does not
radiate below the knee or reaches to the bottom of his foot. Straight posture noted, back is symmetrical.
No tenderness to palpitation of Para spinal muscles and boney prominences of the back. Lumber flexion
is limited to 60 degrees. Lumber flexion is limited to 10 degrees. Ambulation is normal on toes. Heel
walks with difficulty. Muscle strength in upper and lower extremities equal at 5/5. Negative FABER test.
Spine with full ROM. DTR symmetrical. Positive ST. Sensory intact bilaterally.

Neurological: Alert and oriented to person, place, and time. Appropriate behavior, CNII-X11 intact.
Absence of numbness, paralysis, urinary and bowel incontinence.

Lymphatic: Absence of lymphadenopathy.

Diagnostic results:

Cervical X-ray- to determine if the patient has bone misalignment, arthritis, or any fractures.

MRI and CT Scans- to determine if nerves are involved or internal organs. The scans can show if there
are any issues with disk herniation or problems with blood vessels. As well as any issues with the spinal
canal and the surrounding tissues.

Electromyography- can be used to determine electrical impulses that nerves produce as well as muscle
response. It can show if any nerves are compressed due to disk herniation or spinal stenosis (Dains,
Bauman & Scheibel, 2019).

A.

Differential Diagnoses:

Sciatica

The primary diagnosis for the patient that fits the best for the case study is sciatica. Sciatica is
characterized by pain that is developed for disk herniation or spinal stenosis that causes nerve
compression (Furlong et al., 2022). Patients that experience this pain affects the sciatic nerve that
radiates to the lower extremities. The compressed nerve causes nerve inflammation in the lower back
that that also radiates to other parts of the body such as the posterior left leg. Patients will feel
discomfort while sitting for a long time as well as worsening pain with exertion.

Spinal claudication

Spinal claudication is another possible diagnosis for the patient where it is marked by the narrowing of
the spinal canal. The narrowing of the spinal canal results in the increased pressure of the cauda equina
(Kaur et al., 2022). The patient will experience leg and lower back pain and discomfort with exertion. As
well as experiencing numbness and tingling in the lower back and leg.

Peripheral neuropathy
Peripheral neuropathy arises from systemic diseases such as diabetes and metabolic syndrome. Patients
often experience burning, tingling, and numbness pain associated with the affected limb. This diagnosis
is unlikely since the patient does now has a recent infection, diabetes, or metabolic syndrome.

Muscle Strain

A muscle strain is an injury to a muscle or a tendon. It can be a minor injury such as overstretching a
muscle or tendon while severe injuries may cause partial or complete tears in the muscle tissues (Khalid
et al., 2021). Symptoms of low back strain include pain and stiffness in the back. Pain in the buttocks and
the legs, often in the back of the thigh. Pain that worsens when bending, stretching, coughing, or
sneezing. This diagnosis is associated with the patient’s symptoms.

Spinal disk herniation

A herniated disk refers to a problem with one of the rubbery cushions that sit between the bones that
stack of the spine. A spinal disk has a soft, jellylike center encased in a tougher, rubbery exterior (Kaur et
al., 2022). Depending on where the herniated disk is, it can result in pain, numbness, or weakness in an
arm or leg. The patient did not have numbness in his lower extremities so this will be unlikely the
diagnosis for the patient.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in
primary care (6th ed.). Elsevier Mosby.

Furlong, B., Etchegary, H., Aubrey-Bassler, K., Swab, M., Pike, A., & Hall, A. (2022). Patient education
materials for non-specific low back pain and sciatica: A systematic review and meta-analysis. PloS One,
17(10), e0274527. https://doi.org/10.1371/journal.pone.0274527Links to an external site.

Khalid Medani, Kushinga Bvute, Natasha Narayan, Cesar Reis, & Akbar Sharip. (2021). Treatment
outcomes of peri-articular steroid injection for patients with work-related sacroiliac joint pain and
lumbar para-spinal muscle strain. International Journal of Occupational Medicine and Environmental
Health, 34(1), 111–120. https://doi.org/10.13075/ijomeh.1896.01602

Kaur, N., Kaur, N., Chhabra, H., Singh, M., & Singh, P. (2022). A case report of sciatic hernia as a cause of
sciatica and lower back pain: Diagnostic dilemma for family physicians. Journal of Family Medicine &
Primary Care, 11(6), 3304–3307. https://doi.org/10.4103/jfmpc.jfmpc_2057_21Links to an external site.