Episodic/Focused SOAP Note for Lower Back Pain

Patient Information: JB, 41, Male, Hispanic

S.

CC: Lower back pain radiating to left leg

HPI: JB is a 42-year-old Hispanic male who came in for pain in his

lower back for the past month. He states that the pain sometimes
radiates to his left leg. He feels a sharp pain if he moves from side to
side and then sometimes feels spasms while he is sitting. He has not
been able to lay flat and gets some relief when he leans forward. He
states that the pain sometimes is 10 out of 10. He has difficulty
walking without pain. Ibuprofen worked for him at first but it did not
relieve the pain in the last 3 nights.

Current Medications:

Fish Oil 1 capsule daily for supplement

Ibuprofen 400mg PO every 8 hours as needed for pain

Unisom 1 tablet PO every night as needed for insomnia

Allergies: Iodine – causes hives

PMHx:

Childhood Asthma

Radial fracture left arm 2005

Immunization History:

Tdap 10/2018

Influenza vaccine – current

COVID vaccine – first series and 1 booster 11/2022

Soc Hx:

JB is single and works as an electrician. He was in the US Army from

1998-2005. He lives alone in the backhouse of his paternal Aunt’s
property. He goes out and drinks with his friends or co-workers
occasionally. He is sexually active with females. He does not smoke or
take illicit drugs. He is the soccer coach for the high school in his
neighborhood.

Fam Hx:

Mother is 78, has hypertension and dementia, and lives in a memory

care facility

Father passed away from a work accident at 35

Paternal grandparents died when he was young, and the patient does
not know the causes

Maternal grandmother died at 88 and had heart problems, dementia,

and hypertension

Maternal grandfather died at 90 of old age

Paternal Aunt is 65 and has diabetes and kidney disease

He has a sister that lives in Canada and they have not talked to each
other for over 10 years.

ROS:

GENERAL: Denies fever, chills. Complains of weakness or fatigue.

HEENT: Eyes: Denies visual changes.

Ears, Nose, Throat: Denies hearing loss. He has congestion and runny
nose when he starts work but it goes away by mid-morning.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain. Denies palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough, respiratory
allergies, or sputum.

GASTROINTESTINAL: Reports a recent episode of diarrhea that he

thinks came from some bad sushi 2 weeks ago. No abdominal pain or
melena or coffee ground emesis.

GENITOURINARY: Admits to some incontinence because he could not

get to the bathroom in time because of the pain

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis,

ataxia, numbness or tingling in the extremities. Denies any changes in
bowel or bladder control.

MUSCULOSKELETAL: Complains of bilateral upper arm joint pain and

stiff stiffness.

Complains of low back spasms and pain radiating down his legs. He
states that there is a change in the way he gets up and walks.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat

intolerance. No polyuria or polydipsia.

O.

Physical exam:

Vitals: Blood pressure left arm 149/88, HR 98

O2 saturation 98% on room air; respiration 19 breaths per minute;

Temperature 98.9F oral;

Height 5’10”; weight 168 lbs; BMI 24.1

GENERAL: Well-developed and well-nourished Hispanic male, alert

and cooperative, answers questions appropriately, and is well-
groomed.

HEENT: Head normocephalic, without obvious abnormality. Eyes:

PEERLA
Sinuses are clear and are patent bilaterally. NO pain when sinuses are
palpated. Right and Left auditory canals are pink, tympanic membrane
is pearly gray. Throat is moist and pink.

SKIN: Consistent with ethnicity. No bruises or rashes.

CARDIOVASCULAR/PERIPHERAL VASCULAR: S1 & S2 audible. No

jugular distention or bruits. no extremity edema, peripheral pulses
palpable, capillary refill less than 3 seconds.

RESPIRATORY: Lungs auscultated and all lobes clear. Expansion is

symmetrical.

GASTROINTESTINAL: Inspection: No abnormal contours;

Auscultation: Bowel sounds normoactive in all quadrants; Palpation
and percussion: No masses. Liver palpable, dull on percussion, and
spans 8-12 cm. Anal sphincter has tone.

NEUROLOGICAL: Good historian. Able to recall past events without

problems.

MUSCULOSKELETAL: Good Muscle tone. No joint swelling. Pt can flex

head forward 45 degrees, hyperextend 55 degrees, and laterally bend
and rotate head. Sternocleidomastoid and trapezius muscles are
strong. Spine is aligned and body is symmetrical. No bulges along
spine. Some spinal tenderness at L4 & L5. Limited range of motion of
legs due to pain. Unable to adduct legs. Sensations on upper and lower
extremities are intact. Positive Lasegue’s sign.

Diagnostic results:

2 view x-ray of the abdomen and hip. – to detect any broken or

displaced bones

CT scan of the cervical, thoracic, and lumbar spine – used to detect

abnormalities in the bone and spinal cord.

Pre-void and post-void bladder scan – check that the patient does not
have atonic bladder from spinal cord damage

CBC – rule out possible infection

CMP – Electrolyte level

Urinalysis – rule out urinary tract infection

A.

Differential Diagnoses

1. Lower back pain due to muscle strain

Lower back pain can come from different health reasons, and
some are different for men and women. Getting as much information
from the patient is important so that the diagnosis matches the
correct treatment. “The necessity for systematization of therapeutic
procedures results from the fact that back pain causes motor
disability, thereby significantly reducing and even temporarily
disabling motor activity leading to absence from work” (Santos et al.,
2022). When a specific cause is not found, treatment relies on pain
relief of which there are many types. Researchers state that “notable
pain relief with intra-articular anesthetic injection under radiographic
guidance has been shown to provide reliable evidence in the diagnosis
of sacroiliac joint pain” (Thawrani et al., 2019). These injections are
known as epidurals and are used by pain specialists to diagnose and
treat back pain but then the treatment may hide other underlying
causes that may not yet have been found.

Consequently, the Agency for Healthcare Research and

Quality (AHRQ) advocates for patients and is committed “to identifying
pain management therapies that provide value to the patient and
society through measurable improvements in pain and physical
functioning with no or minimal adverse events” (Berliner, 2016). In
their quest for evidence-based treatments, they find that “there is
ample experimental and clinical evidence that radicular pain has an
inflammatory basis and is potentially susceptible to targeted delivery
of an anti-inflammatory agent to the interface of neural tissue and the
compressive lesion” (Berliner, 2016). This guides providers to look for
other treatments and not try opioid medications as a first-line
treatment. The patient JB was using ibuprofen and it was working. A
higher dose or another type of anti-inflammatory medication or steroid
is a better choice to treat him and see if it works.

2. Lumbar Radiculopathy

Lumbar radiculopathy (LR) also known as sciatica, is a

common complaint and starts to affect people when they reach middle
age. According to Berry et al.(2019), patients with LR commonly
present with pain that radiates down the legs and “is often described
as electric, burning, or sharp.” JB falls is 41 years of age and
describes his pain as radiating, sharp, and spasms at times. “Sciatica
is a clinical diagnosis based on symptoms of radiating pain in one leg
with or without associated neurological deficits on examination”
(Jensen et al., 2019). Currently, JB has not shown any other
neurological deficits. “The most common underlying cause of
radiculopathy is irritation of a particular nerve, which can occur at any
point along the nerve itself and is most often a result of a compressive
force” and “in the case of lumbar radiculopathy, this compressive
force may occur within the thecal sac.” (Berry et al., 2019). Tests can
be costly and not definitive but one test that can be done in an office
or clinic is a Lasegue’s sign. “Lasegue’s sign is assessed with the
patient lying in the supine position, the knee extended, the ankle
dorsiflexed, and the cervical spine flexed. The examiner lifts the
patient’s lower extremity off the table towards 90 degrees, which will
elicit radicular pain as the nerve root is stretched” (Berry et al., 2019).
Also, a thorough exam of any injuries that JB had in the past will rule
out whether started as an injury or from repetitive movements. As an
electrician, his job requires a lot of upper body movements which may
be contributing to the pain.

3. Cauda Equina Syndrome

Another possible diagnosis for JB is cauda equina syndrome

(CES) but it is rare and often is misdiagnosed. According to Long et al.
(2019), “cauda equina syndrome is a rare but emergent condition
associated with back pain and other symptoms resulting from
compression of the cauda equina” which “is comprised of the second
through fifth lumbar nerves, sacral nerves, and coccygeal nerve and
begins in the medullary cone.” It is debilitating and sometimes
overlooked but there are simple tests to rule out more common causes
of back pain. Besides back pain, the other “symptoms include
unilateral or bilateral sciatica, decreased perianal region sensation,
fecal and bladder disruption, lower extremity weakness, and reduced
sexual function” (Long et al., 2020). A pre-void and post-void scan will
determine if JB has bladder atony and checking for anal sphincter tone
will determine if he can still feel the need to hold bowel movements.
4. Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) “diagnosis can generally be

made based on a clinical history of back and lower extremity pain that
is provoked by lumbar extension, relieved by lumbar flexion, and
confirmed with cross-sectional imaging, such as computed
tomography or magnetic resonance imaging (MRI)” (Katz et al., 2022).
LSS develops over time unless it is due to an injury. It affects the
lower body and contributes to falls.

This section is not required for the assignments in this course (NURS
6512) but will be required for future courses.

References

Berliner, E. (2015). Multisociety Letter to the Agency for Healthcare

Research and Quality: Serious methodological flaws plague technology
assessment on pain management injection therapies for low back
pain. Pain Medicine, n/a. https://doi.org/10.1111/pme.12934

Berry, J. A., Elia, C., Saini, H., & Miulli, D. E. (2019). A review of lumbar
radiculopathy, diagnosis, and treatment. Cureus.
https://doi.org/10.7759/cureus.5934

Jensen, R. K., Kongsted, A., Kjær, P., & Koes, B. W. (2019). Diagnosis
and treatment of sciatica. BMJ, l6273.
https://doi.org/10.1136/bmj.l6273

Katz, J. N., Zimmerman, Z. E., Mass, H., & Makhni, M. C. (2022).

Diagnosis and management of lumbar spinal stenosis. JAMA, 327(17),
1688. https://doi.org/10.1001/jama.2022.5921

Long, B., Koyfman, A., & Gottlieb, M. (2020). Evaluation and

management of cauda equina syndrome in the emergency
department. American Journal of Emergency Medicine, 38(1), 143–
148. https://doi.org/10.1016/j.ajem.2019.158402

Santos, G. K., De Oliveira, R. G., De Oliveira, L. C., De Oliveira, C. F. C.,

Andraus, R. A., Ngomo, S., Fusco, A., Cortis, C., & Da Silva, R. A.
(2022). Effectiveness of muscle energy technique in patients with
nonspecific low back pain: a systematic review with meta-
analysis. European Journal of Physical and Rehabilitation
Medicine, 58(6). https://doi.org/10.23736/s1973-9087.22.07424-x
Thawrani, D., Agabegi, S. S., & Asghar, F. A. (2019). Diagnosing
sacroiliac joint pain. Journal of the American Academy of Orthopaedic
Surgeons, 27(3), 85–93. https://doi.org/10.5435/jaaos-d-17-00132