NU610 SOAP Note Case

NU610 SOAP Note Case

A 35-year-old male presents with the onset of acute low back pain.  He was doing some yard work, including pulling out large bushes, when he experienced the acute onset of low back pain, radiating down the back of the left leg. Since then, the pain has worsened in intensity, and he is having difficulty bearing weight on the leg. He initially took 800 mg ibuprofen, which provided a small degree of relief, but he has not taken any medication since the problem initially occurred. The patient has no significant medical history. His general physical examination is within normal limits with regards to cardiovascular and pulmonary system.  On neurological examination, he has severe pain with active movement of the lower extremity, but only minimal pain with passive movement of the lower extremity. He has a positive straight leg raise but no other neurological deficits.  Check tips on how to do your Soap Note Assignment. 

NU610 SOAP Note Case

Denies loss of bowel or bladder or saddle anesthesia.  Denies fever, chills, weight loss or weight gain.  Denies headaches, dizziness, rashes or bruising.  Denies history of lower back pain or previous injury to back.  He is recently divorce and shares custody of three children.  He reports smoking about 1 pack of cigarettes a day for 10 years but quit 5 years ago, currently vapes daily.  He reports one beer with dinner, denies illicit drug use. Denies hospitalizations or surgical history.  He does not get regular health maintenance and only sees primary care provider when has acute issue.  He works for IT department from home and sits about 8 hours per day.  He reports running at least 30 minutes daily and overall eats “healthy.”  Denies family history of spine or musculoskeletal diseases or malignancy.  VS in office BP 124/78, HR 79, RR 16, Temp 97.3, 100% on RA.  Appears in acute distress related to pain.  Rates pain 8 out of 10, described as sharp, lightening sensation.

NU610 SOAP Note Case

What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.

Use the “OLDCART” approach for collecting data and documenting findings.

State the offending medication/food and the reactions.

Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.