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Episodic/Focused SOAP Note Template
Patient Information:
AS, 42, male, Caucasian
S.
CC (chief complaint) “lower back pain”
HPI: patient is a 42-year-old Caucasian male with a complaint of pain in his lower back for the past month. Patient states that the pain sometimes radiates to his left leg.
Location: lower back
Onset: past month
Character: sometimes radiates to his left leg.
Associated signs and symptoms: What aggravates the pain?
Timing: is there specific time that the pain is more
Exacerbating/ relieving factors: What helps or worsen the pain
Severity: 7/10 pain scale
Current Medications: ask for medication including dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products as well as when the last dose was taken.
Allergies: include medication, food, and environmental allergies and a description of the allergy signs and symptoms.
PMHx: include immunization status; include date of last dose of tetanus shut; any major illnesses and surgeries.
Soc Hx: include patient’s job and hobbies, marriage and family status, use of tobacco, alcohol, or illicit drugs both previous and current. Use of seat belts; text/cell phone use while driving, working smoke detectors in the house, safe living environment, and support system.
Fam Hx: past and present illnesses with possible genetic predisposition, contagious or chronic illnesses parents, grandparents, siblings, and children. Include the cause of death of any deceased first degree relatives.
ROS:
GENERAL: Patient denied any recent weight gain, no fever, no chills, and no weakness
HEENT: Eyes: No headache, no abnormal vision changes or yellow sclera. No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denied any skin rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denied burning on urination or any urinary problem.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: complained of low back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety. Denied any suicidal or homicidal thoughts
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam:
General: Patient came in alert and oriented x 4 but anxious. Well developed and well groomed. Speech was clear with normal thought process. He was cooperative with assessment and voluntarily gave information.
Walk Test: to see how patient’s spine carries his weight (Cleveland clinic, 2020). Assessing patient walking on his toes and heels helps to check the strength of his calf muscles (Cleveland clinic, 2020).
Straight leg test: Raising each leg slowly while lying on his back with legs straight (from angle 35 to 75 degrees) helps to identify the specific area that pain begins, and the specific nerves and disks affected (Cleveland clinic, 2020). Other stretches and movement may also help to check muscle flexibility and strength (Cleveland clinic, 2020).
Head: EENT: No sign of head injury; no visual or hearing problem; No shortness of breath or distress.
Vital signs will be checked and recorded. Height and weight will be measured and recorded.
Current pain level will be noted.
References: