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Episodic/Focused SOAP Note Template
DW 45 Caucasian Male
HPI: David reports suffering from lower back pain. The pain
started approximately one month ago. It is a burning shooting pain that
radiates to his left leg. Sometime the pain is associated with numbness
in the left foot and tingling in the left leg. He mostly notices the
pain when he’s been standing for an extended period of time. Standing
makes the pain worse but sitting seems to help. David has tried over the
counter medications including Tylenol, Motrin, and Aleve but none of
those seem to make a difference. He’s also recently found some
stretching videos online that seem to help reduce the number of what he
refers to as ‘flare ups’ each day. He rates the pain as a 7/10 when he
experiences it but denies pain at this time.
Current Medications: None
PMHx: Childhood immunizations are up to date. Received the flu shot last week. Last Tetanus 2014.
Soc Hx: David is a construction worker and cleans pools on the
weekend. He is married with 2 adult children. David SCUBA dives and sky
dives recreationally but hasn’t recently. He denies any use of alcohol
or recreational drugs. David was a pack/day smoker for 12 years but quit
15 years ago. David never goes to the doctor but regularly monitors his
blood pressure at his local pharmacy. He does not have health
Fam Hx: Father: deceased at 81- stroke. Mother: deceased at 83
Alzheimer’s disease. Brother: deceased at 32- suicide. Sister: 41-
Breast CA at 30. 3 other sisters and 2 brothers living. No other
pertinent family history.
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia. No
change in bowel or bladder control. Numbness noted on occasion to left
lower leg and foot and tingling the radiates up and down his left leg.
Weakness when standing for long periods.
MUSCULOSKELETAL: Lower burning back pain that radiates to the left leg.
Physical exam: From head-to-toe, include what you see, hear, and
feel when doing your physical exam. You only need to examine the systems
that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
VS: BP 128/76; P 77; R 22; T 97.8; 02 98% Wt 220lbs; Ht 70”
General–Pt appears in good health with a apple shaped abdomen. Appropriate. Alert, oriented.
Cardiovascular–PMI is in the 5th inter-costal space at the mid
clavicular line. S1,S2. No murmur. No edema. Good radial and DP pulses.
Cap refill <3secs.
Pulmonary— Lungs are clear to auscultation and percussion bilaterally.
Neurological— Good strength in all ext against resistance. Able
to lift legs bilaterally and hold. Pain in left buttock and lower back
when lifting left leg off the bed. Differentiates between sharp and dull
sensations throughout both lower extremities. No numbness or tingling
at this time.
Musculoskeletal –Complains of pain in lower back and left buttock
when lifting left leg off bed. Describes pain in lower back when
walking on toes and heels. Complains of pain when asked to stand from a
Diagnostic results:Diagnostic results: MRI shows herniated disk at L1-L2.
1) Herniated disk. This can cause nerve root irritation that may travel below the knee (Dains, 2019).
2) Sciatica. The most common cause is a herniated vertebral disk or
spinal stenosis (Mayo Clinic, 2019)Low levels of physical activity and
obesity increase a patient’s risk of radiating low back pain (Shiri,
2013). Occupations that require twisting and bending or carrying heavy
loads can lead to sciatica pain(Mayo Clinic, 2019).
3) Musculoskeletal strain. With this type of injury, patients often
report pain that is exacerbated by sitting or standing for long periods
of time (Dains, 2019). Patients often describe relief from pain with
rest, as seen in this case (Dains, 2019).
4) Spinal Stenosis. Spinal stenosis will result in pain while
walking or standing for long periods of time that often gets better with
rest or forward flexion of the spine (Dains, 2019). It is most often
seen in patients over the age of 50 (Dains, 2019).
5) Tumor. This is unlikely, but possible. Patients with tumors
usually present with weight loss, fatigue, weakness and anemia (Dains,
Primary Diagnosis/Presumptive Diagnosis: Herniated Disk and related sciatica pain.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Dains, J. E. (2019). Advanced health assessment and clinical diagnosis in primary care(Vol. 6). St.Louis, Missouri: Elsevier Mosby.
Mayo Clinic. (2019, September 26). Sciatica. Retrieved from Mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/sciatica/diagnosis-treatment/drc-20377441
Shiri, R. S.-P.-J. (2013). The role of obesity and physical activity
in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640-650.
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