A Detailed SOAP Note Case Study : Managing Chronic Low Back Pain

This comprehensive SOAP note for Mr. Smith provides a detailed assessment and plan for his lower back pain while considering his medical history, social factors, and a patient-centered approach to care.

SOAP notes are vital tools for healthcare providers to document patient encounters, ensure effective communication, and provide the best possible care.

Patient Information:

  • Name: John Smith
  • Age: 42
  • Gender: Male
  • Date of Visit: 07/15/2023
  • Chief Complaint: Lower back pain and muscle stiffness

Subjective:

Mr. Smith is a 42-year-old male who presents with complaints of persistent lower back pain and muscle stiffness for the past six weeks. He describes the pain as a constant, dull ache that is primarily located in the lumbar region. The patient reports that the pain is more pronounced in the morning and gradually improves throughout the day but never completely resolves. He denies any recent trauma or injury to the back. Mr. Smith reports that the pain limits his ability to perform his daily activities, including walking, bending, and lifting. He rates the pain as a 6 out of 10 on a visual analog scale (VAS).

He states that over-the-counter pain relievers, such as ibuprofen, provide minimal relief and that he has not seen any improvement with rest. He denies any radiating pain or numbness into his legs, changes in bowel or bladder function, or any recent weight loss. Mr. Smith also mentions that he works as an office manager and spends prolonged hours sitting at his desk.

Medical History:

Mr. Smith’s past medical history is significant for hypertension, which is well-controlled with amlodipine (5 mg daily). He has no history of diabetes, heart disease, or prior surgeries. He is not currently taking any other medications and has no known allergies.

Social History:

Mr. Smith is a non-smoker and does not consume alcohol. He is married and lives with his wife and two children. He works a desk job and reports that his daily routine involves limited physical activity.

Objective:

Vital Signs:

  • Blood Pressure: 130/80 mm Hg
  • Pulse: 72 bpm
  • Respiratory Rate: 18 bpm
  • Temperature: 98.6°F
  • Height: 6 feet
  • Weight: 190 lbs
  • Body Mass Index (BMI): 25.8 (within normal range)

Physical Examination: Upon examination, Mr. Smith appears well-nourished and in no acute distress. Inspection of the lumbar spine reveals no visible deformities or asymmetry. Palpation of the lower back elicits tenderness over the lumbar paraspinal muscles. There is no evidence of swelling or skin abnormalities. Range of motion of the lumbar spine is limited due to pain, with forward flexion causing increased discomfort. Straight leg raising test is negative.

Muscle strength and tone in the lower extremities are within normal limits, and there are no sensory deficits noted. Deep tendon reflexes (patellar and Achilles) are brisk and symmetrical. There is no evidence of muscle atrophy or fasciculations.

Assessment:

Based on the patient’s history and physical examination, the following assessments are made:

  1. Chronic Mechanical Low Back Pain: Mr. Smith’s presentation of persistent lower back pain, worsened with prolonged sitting, and improved with activity, is consistent with chronic mechanical low back pain. The absence of radicular symptoms, sensory deficits, or motor weakness suggests a non-specific etiology.
  2. Hypertension: Mr. Smith has a known history of well-controlled hypertension, currently managed with amlodipine.

Plan:

  1. Pain Management:
    • Initiate conservative treatment for chronic mechanical low back pain.
    • Recommend physical therapy to address muscle imbalances, improve core strength, and educate on proper posture and ergonomics.
  2. Medication:
    • Consider non-prescription pain relief options like acetaminophen or NSAIDs for pain management as needed, ensuring Mr. Smith’s blood pressure remains well-controlled.
  3. Lifestyle Modification:
    • Advise Mr. Smith to avoid prolonged sitting and to take breaks to stand and stretch at work.
    • Encourage the use of lumbar support and ergonomic chair at his desk.
  4. Follow-Up:
    • Schedule a follow-up appointment in two weeks to assess the response to conservative treatment.
    • Discuss the possibility of imaging studies (e.g., X-ray or MRI) if there is no improvement or if there are any red flag symptoms (e.g., unexplained weight loss, neurologic deficits).
  5. Hypertension Management:
    • Continue current medication (amlodipine) for hypertension.
    • Monitor blood pressure regularly to ensure it remains within target range.
    • Review lifestyle modifications for blood pressure control, including dietary changes and stress reduction.

Education:

Mr. Smith was educated on the importance of maintaining good posture, regular exercise, and the potential benefits of physical therapy. He was also instructed to seek immediate medical attention if he experiences any worsening of his symptoms or the development of any concerning neurological symptoms, such as weakness, numbness, or bowel or bladder dysfunction.

Follow-up Instructions:

Mr. Smith is scheduled for a follow-up appointment on 07/29/2023, during which his progress will be assessed, and further management options will be discussed based on his response to conservative treatment.

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