HPI: This 42-year-old Caucasian male presents to the clinic today with lower back pain with intermittent sharp,
FIRST POST
Episodic/Focused SOAP Note/ Low Back Pain
Patient Information:
Initials MJ, Age 42, Sex Male, Race: Caucasian
S.
CC “I’ve had lower back pain for about a month now. It sometimes feels like a spasm, and the pain shoots down my left leg.”
HPI: This 42-year-old Caucasian male presents to the clinic today with lower back pain with intermittent sharp, shooting pains down the posterior of the left leg accompanied by numbness and tingling. His pain started after he started a new desk job where he sits for most of the day. His back pain started out as a throbbing, dull ache and gradually got worse until today, when he awoke to a sharp pain in his left leg as he got out of bed. On a scale of 1-10, he rates the pain as 7. According to the patient, putting pressure on the left leg to walk makes the pain worse. He has tried applying heat and ice to the area and has taken Ibuprofen to relieve the pain with little relief.
Current Medications:
Ibuprofen 600 mg qhs po as needed for pain
Men’s One a Day vitamin 1 po qd
Allergies: Amoxicillin (Hives) Denies food, environmental or latex allergy.
PMHx: All immunizations are up to date. Last tetanus 2/2020. Tonsillectomy at age 5. Denies major illnesses.
Soc Hx: Patient works as a computer engineer at Microsoft. Married for 12 years and has two children. A son who is 8 and a daughter who is 5. He enjoys golfing, snow, and water skiing. Denies tobacco use and drinks 3-4 beers on weekends. Denies illicit drug use however “smoked pot in college” Wears his seat belt while driving. Does not text while driving and has a good support system at home.
Fam Hx:
Father: HTN, hyperlipemia, Age 68
Mother: Hypothyroidism, arthritis, Age 67
Brother: HTN, age 44
Sister: Healthy, Age 38
MGM: Deceased at age 85 from stroke. HTN, hyperlipidemia
MGF: Deceased at age 82 from colon cancer
PGM: Deceased at age 82: Osteoporosis
PGF: Deceased: DMT2, Hyperlipidemia
Son: No medical conditions
Daughter: No medical conditions
ROS:
GENERAL: Denies fever, chills, night sweats, weakness, or weight loss/gain
HEENT: Eyes: Denies vision changes, denies excessive tearing or discharge from eyes. Ears, denies hearing loss or tinnitus, or pain. Nose: Denies epistaxis, sneezing, congestion and denies loss of smell or taste. Throat: Denies sore throat or painful swallowing, hoarseness. Last dental exam was 10/2021. Has own teeth.
SKIN: Denies any new rashes or lesions
CARDIOVASCULAR: Denies any palpitations, chest pain, or edema. Denies chest tightness.
RESPIRATORY: Denies cough, shortness of breath, or orthopnea
GASTROINTESTINAL: Denies nausea, vomiting, and diarrhea. Denies anorexia, nausea, denies abdominal pain or blood.
GENITOURINARY: Denies urinary frequency, dysuria, or hematuria. Denies changes in bladder pattern
NEUROLOGICAL: Denies dizziness, syncope, gait disturbances, or weakness. Positive for tingling in the left leg. Denies ataxia, no change in bowel or bladder control.
MUSCULOSKELETAL: Reports low back pain x 1 month ago. Reports pain that is intermediate. Reports sharp shooting pain down the left leg. Denies trauma, has some trouble ambulating from a sitting position to walking without pain.
HEMATOLOGIC: Denies bruising easily
LYMPHATICS: No lymphadenopathy, No history of splenectomy.
PSYCHIATRIC: Grossly intact. No history of depression or anxiety. Denies suicidal ideation.
ENDOCRINOLOGIC: Denies night sweats, cold or heat intolerance, no polyuria or polydipsia
O.
Physical exam:
Vital signs: T 98.4, HR 75, R 19, BP 132/70, SAT 98%, WT 200 lbs., HT 5’9, BMI 29.5
General: Patient appears to be alert, oriented, calm and relaxed in no apparent distress.
HEENT: Normocephalic, atraumatic, PEARL bilaterally. TMs intact bilaterally without erythema or effusion. Nares patent with no polyps. Nasal mucosa pink and moist. No discharge or swelling noted. Oropharynx without tonsils. No erythema, or exudates. Buccal mucosa moist without lesions. Teeth stable. No gingivitis noted.
Neck: Supple, full ROM. Thyroid moves freely with swallow test with no nodules or masses. No lymphadenopathy. Trachea at the midline. No carotid bruits noted. No JVP. JVP 4cm at 45-degree elevation.
Lungs: Clear to auscultation bilaterally, no retractions
CV: RRR without murmur, gallops, heaves or lifts. Femoral pulses +2 bilaterally.
Musculoskeletal: Spine aligned vertically. Normal S curvature. Palpation does not reveal any nodules, masses, or tenderness. All extremities have full range of motion. There is no swelling or erythema in the joints. Proper alignment of the knees and feet. Positive Bragard stretch test on the left leg at 50%. Left-sided palpation of the nerve trunk reveals tenderness at the sciatic notch.
Neurological: The cranial nerves II to XII are intact. The sensory system is intact. Motor is 5/5. All other reflexes are 2/4, no clonus. Romberg is negative. Gait is balanced and coordinated without ataxia.
Diagnostic results: Patients with acute low back pain are initially assessed for “red flags” (indicators of potentially serious spinal pathology). In the absence of red flags, imaging studies and further testing of patients are not usually helpful during the first 4 weeks of low back symptoms. Further evaluation may be necessary if low back symptoms persist. Sciatica patients may recover more slowly, but further evaluation can also be delayed safely (Bigos, 1994).
A.
Differential Diagnoses:
Sciatica: Sciatica is commonly used to describe radiating leg pain. It is caused by inflammation or compression of the lumbosacral nerve roots (L4-S1) forming the sciatic nerve. Sciatica can cause severe discomfort and functional limitation. Unilateral leg pain more severe than low back pain. Pain most commonly radiating posteriorly at the leg and below the knee. Numbness and/or paranesthesia in the involved lower leg. Positive neural tension test with provocation of pain in the affected leg straight leg raise test/femoral nerve test/slump test) Neurological deficit associated with the involved nerve root (Jensen et al., 2019).
Lumbar disk herniation: Approximately 5–15% of patients with low back pain suffer from lumbar disc herniation (LDH). LDH is the most common spine disorder requiring surgical intervention. Clinical guidelines recommend history taking and physical examination to rule out LDH diagnosis. However, the diagnostic accuracy of both history taking and physical examination is still insufficient. Diagnostic imaging in patients with back pain and/or leg pain is often used to assess nerve root compression due to disc herniation or spinal stenosis and cauda equina syndrome (Kim et al., 2018).
Spinal stenosis: Spinal stenosis occurs when your spine narrows, putting pressure on the nerves in the spine. The lower back and neck are the most common sites of spinal stenosis. It is possible for people with spinal stenosis to have no symptoms. Other symptoms may include pain, tingling, numbness, and weakness of the muscles. Over time, symptoms can worsen. In most cases, spinal stenosis is caused by osteoarthritis-related wear-and-tear. In severe cases of spinal stenosis, doctors may recommend surgery to create additional space for the spinal cord (Mayo Clinic, 2020).
References
Ball, J., Seidel, H. M., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s Guide to Physical Examination: An interprofessional approach. Elsevier.
Bigos, S. J. (1994). Acute low back problems in adults. U.S. Dept. of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research.
Domino, F. J., Baldor, R. A., Berry, K., Golding, J., & Stephens, M. B. (2022). The 5-Minute clinical consult 2022. Lippincott Williams & Wilkins.
Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ, l6273. https://doi.org/10.1136/bmj.l6273
Kim, J.-H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., Ostelo, R. W., van der Windt, D. A., & Verhagen, A. P. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropractic & Manual Therapies, 26(1). https://doi.org/10.1186/s12998-018-0207-x
Mayo Foundation for Medical Education and Research. (2020, October 24). Spinal Stenosis. Mayo Clinic. Retrieved July 19, 2022, from https://www.mayoclinic.org/diseases-conditions/spinal-stenosis/symptoms-causes/syc-20352961#:~:text=Spinal%20stenosis%20is%20a%20narrowing,stenosis%20may%20not%20have%20symptoms.
Sullivan, D. D. (2019). Guide to clinical documentation. F.A. Davis Company.
SECOND POST
Episodic/Focused SOAP Note Template
Patient Information:
AD, 42, M, Asian
S.
CC: “Back hurts for a month”
HPI: AD is a 42-year-old Asian male brought in by wife seeking care for low back pain that “sometimes” radiates to LLE x1 month. Usually active in sports (basketball and golf) but has not been for the past two weeks due to pain. Pain is currently 8/10 but has been as high at 9/10. Pain is constant “throbbing”, and can be “like lightning”, sharp, and shooting depending on position and quick body movements. Complains of intermittent numbness to LLE, denies tingling. Takes ibuprofen and immobilizes with temporary relief. Last ibuprofen “before bed last night”. Did not want to take medication this AM prior to arrival. Denies recent trauma, fever, chills, n/v/d. Denies surgical history. Denies recent travel or illness.
Current Medications: amlodipine 5mg daily, rosuvastatin 10mg daily, Men’s Centrum Silver daily, ibuprofen 600mg q6h prn
Allergies: NKA
PMHx: Pneumovax 2021, tdap 2015. All other immunizations up to date per EHR/state registry records. HTN x2 years, Dyslipidemia x2 years. No surgical history.
Soc Hx: AD is married with 2 children. Lives in a trilevel home. Has a masters and works as a systems engineer at Boeing. In a local basketball league and plays golf. Tobacco use “on occasion”, ETOH use on occasion – “3-4 drinks on weekends with friends after playing ball or golf”. Uses seatbelts. Has working smoke/carbon monoxide detectors. Denies texting and driving. Positive family dynamics and support – has help with kids from parents and in-laws.
Fam Hx:
Mother – alive age 70, HTN, HLD
Father – alive age 71, HTN, HLD, gout, smoker, renal stones
Maternal grandmother – Deceased age 78, “old age”
Maternal grandfather – Deceased age 82, prostate ca
Paternal grandmother – Deceased age 84, “old age”, HTN, HLD
Paternal grandfather – Deceased age 88, COPD, smoker
Son – Alive age 4 – “healthy”
Son – Alive age 6 – “healthy”
ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, diarrhea, constipation. No abdominal pain or blood. Last BM this AM.
GENITOURINARY: Denies dysuria, anuria, oliguria, increased frequency.
NEUROLOGICAL: +intermittent numbness to LLE. Denies tingling. Denies headache, dizziness, syncope, paralysis, or ataxia in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: +lumbar pain, radiating to LLE.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam:
Vital signs: Ht: 5’7” wt 155 lbs BMI 24.3 T 32.2C P 100 R 24 BP 120/76 SpO2 99% room air
General: A/Ox3 42-year-old Asian male. Appears stated age. Good historian. Well-kept. Answers questions appropriately. Grimacing while walking and with certain positioning. Steady gait and balance. Favors LLE. Slightly tachypneic.
HEENT: Symmetric. No drainage.
Cardiology: RRR. S1, S1. No murmurs, gallops.
Respiratory: Lung sounds CTA bilaterally. Equal chest rise and expansion bilaterally. Slightly tachypneic. No accessory muscle use.
GI: Non-tender/non-distended. No organomegaly.
GU: No CVA tenderness.
MSK: No scoliosis, kyphosis, lordosis. +tenderness L4-S1, +Straight leg test at 45 degrees on LLE – supine position. +tripod posture in sitting position. Strength 4/5 LLE, 5/5 RLE.
Psychiatric: Pleasant, cooperative.
Neuro: CN II – CN XII grossly intact. DTR intact. Decreased sensation to LLE.
Diagnostic results: Awaiting results. 3 view lumbar/spine X-ray, MRI without contrast lumbar/spine.
A.
Differential Diagnoses:
DDX: Sciatica – highly likely given presenting symptoms and objective data. Obtain lumbar/spine x-ray to rule out fracture – given patient is active in sports including golf, or tumor (Jensen et al., 2019). Obtain MRI lumbar/spine to eval for radiculopathy considering red flags of tenderness to lumbar region with positive supine straight leg test at 45 degrees, decreased strength and sensation to LLE. Negative for cauda equina syndrome – associated symptoms involving bowel and bladder (Hutchins et al., 2021; Varrassi et al., 2021). Sciatic nerve is composed from L4 – S2 nerve roots and fused in the pelvic cavity, terminating in the posterior knee (Davis, Maini, & Vasudevan, 2022).
DDX: Spondylolisthesis – likely given presenting symptoms and objective data with low back pain and radicular leg pain. Also active in sports possibly creating biomechanical changes and stress to vertebrae and associated nerve roots in the lumbar/sacral region (Alomari et al., 2022). Obtain X-ray lumbar spine (AP, lateral, lumbosacral), MRI lumbar/spine.
DDX: Ankylosing spondylitis (AS) – unlikely given non-systemic symptoms and patient’s pain is positionally related radiating to LLE, not localized to hip/joint. However, pt is of Asian descent, obtain MRI lumbar/spine, ESR, CRP, CBC to rule out inflammatory processes (Wu et al., 2021; Zhu et al., 2019).
DDX: Lumbar muscular sprain/strain – not likely given pain radiating unilaterally to LLE. As above – obtain lumbar/spine xray to rule out fracture (Jensen et al., 2019). Obtain MRI lumbar/spine.
DDX: Lumbar spondylosis – not likely given age, BMI in healthy category, presenting symptoms, and objective data. However, given basketball and golf activity, may contribute to spine loading. Obtain MRI lumbar/spine (Middleton & Fish, 2009).
P.
References
Alomari, S., Judy, B., Sacino, A. N., Porras, J. L., Tang, A., Sciubba, D., Witham, T., Theodore, N., & Bydon, A. (2022). Isthmic spondylolisthesis in adults… a review of the current literature. Journal of Clinical Neuroscience, 101, 124–130. https://doi.org/10.1016/j.jocn.2022.04.042
Hutchins, T. A., Peckham, M., Shah, L. M., Parsons, M. S., Agarwal, V., Boulter, D. J., Burns, J., Cassidy, R. C., Davis, M. A., Holly, L. T., Hunt, C. H., Khan, M. A., Moritani, T., Ortiz, A. O., O’Toole, J. E., Powers, W. J., Promes, S. B., Reitman, C., Shah, V. N., … Corey, A. S. (2021). ACR appropriateness criteria® low back pain: 2021 update. Journal of the American College of Radiology, 18(11). https://doi.org/10.1016/j.jacr.2021.08.002
Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ, l6273. https://doi.org/10.1136/bmj.l6273
Middleton, K., & Fish, D. E. (2009). Lumbar spondylosis: clinical presentation and treatment approaches. Current reviews in musculoskeletal medicine, 2(2), 94–104. https://doi.org/10.1007/s12178-009-9051-x
Varrassi, G., Moretti, B., Pace, M. C., Evangelista, P., & Iolascon, G. (2021). Common Clinical Practice for Low Back Pain Treatment: A Modified Delphi Study. Pain and therapy, 10(1), 589–604. https://doi.org/10.1007/s40122-021-00249-w
Wu, X., Wang, G., Zhang, L., & Xu, H. (2021). Genetics of ankylosing spondylitis—focusing on the ethnic difference between East Asia and Europe. Frontiers in Genetics, 12. https://doi.org/10.3389/fgene.2021.671682
Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., Qiu, G., Cao, X., & Weng, X. (2019). Ankylosing spondylitis: Etiology, pathogenesis, and treatments. Bone Research, 7(1). https://doi.org/10.1038/s41413-019-0057-8
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