HPI: 42-year-old obese female presents with complaints of lower back pain for the past week that feels worse today. The pain is constant and intermittently radiates down her left leg. It is not improved with ibuprofen. She works as a grocery store clerk.
Review of systems:
General: No fever, chills, or weight changes or sweating or general weakness.
Eyes: No blurred or double vision or pain or redness.
Ears: No pain or decrease in hearing.
Nose: No runny nose or blockage or bleeding.
Throat: No sore throat.
Head: No headache.
Chest: No chest pain or cough or shortness of breath or wheezing.
Breasts: No pain or tenderness or noticeable lump.
Heart: No irregular heart beat or palpitations or chest pain.
Gastrointestinal: No nausea or vomiting or constipation or difficulty swallowing or rectal bleeding or bloating or distension or hemorrhoids or diarrhea or abdominal discomfort.
Genitourinary: No vaginal discharge or bleeding or dysuria or vaginal problems.
Musculoskeletal: No muscle problems or weakness. Lower back pain that radiates down left leg.
Skin: No rashes or bruises or skin masses or other skin complaints.
Neurologic: No weakness or headache or seizures or numbness or tingling.
Psychiatric: No anxiety or depression or suicidal/homicidal thoughts.
Endocrine: No excessive thirst or excessive urination or excessive heat or cold.
Immunologic: No tuberculosis or hepatitis or HIV or recurrent infections.
Hematologic: No anemia or easy bruising or bleeding.
Lower back pain soap note examples
PMHx: none
FamilyHx: none
SocialHx: Pt works as a grocery store clerk
Allergies: NKA
Objective:
66 in
275 lb
44.4
122/75 mmHg
78 bpm
14 bpm
97.6 °F
99 %
General: Normotensive, in no acute distress.
Head: Normocephalic, no lesions.
Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.
Ears: EAC’s clear, TM’s normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: Physiological, no localizing findings.
Skin: Normal, no rashes, no lesions noted.
Lower back pain soap note examples
Assessment:
Actual Dx:
ICD-10-CM Codes. (2019). Retrieved from https://www.icd10data.com/ICD10CM/Codes/
Plan:
– begin medications listed below as needed.
– pt educated on importance of weight loss and dietary modification to reduce back strain
– RTC for follow up in 30 days if symptoms persist
Ultram, Flexeril: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (2019). Retrieved from https://www.webmd.com/drugs
Education:
Provide education to pt on importance of dieta
Order this paper