SOAP Note Template

Encounter date: October 30, 2023

Patient Initials: J.D. Gender: M Age: 45 Race: Caucasian Ethnicity: Non-Hispanic

Reason for Seeking Health Care: The patient presents for a follow-up regarding persistent lower back pain and recent migraines.

Subjective (S - Chief Complaint): The patient reports experiencing severe and persistent lower back pain for the last six months. He describes it as a dull ache combined with intermittent sharp pains, rated 8/10 on the pain scale, limiting his mobility and impacting daily activities. Additionally, the patient reports experiencing frequent migraines over the past month, lasting several hours, often accompanied by sensitivity to light and nausea.

Allergies: No known drug, food, latex, environmental, or herbal allergies were reported.

Current perception of Health: Fair

Past Medical History:

Major/Chronic Illnesses: Hypertension, hypercholesterolemia.

Trauma/Injury: None reported.

Hospitalizations: Appendectomy in 2010 for acute appendicitis.

Past Surgical History: Appendectomy in 2010.

Medications:

Lisinopril 10mg once daily for hypertension

Atorvastatin 20mg once daily for high cholesterol

Over-the-counter ibuprofen as needed for pain relief

Family History:

Father: Hypertension

Mother: Diabetes

No reported family history of cancer or heart disease.

Social History:

Lives: Single-family house with stairs Marital Status: Single

Employment Status: Employed Current/Previous Occupation Type: Software Engineer

Exposure to: Smoke: Non-smoker ETOH (Alcohol): Occasional alcohol consumption, socially. Recreational Drug Use: No reported recreational drug use.

Sexual Orientation: Heterosexual Sexual Activity: Active Contraception Use: Condoms

Family Composition: Lives alone

Health Maintenance:

Screening Tests: The patient is up to date with recommended screening tests.

Mammogram: The last mammogram was conducted in 2022 and was normal.

PSA (Prostate-Specific Antigen): No relevant history for PSA testing.

Colonoscopy: No relevant history for colonoscopy.

Pap Smear: The last Pap smear was conducted in 2021, and the results were normal.

1. Exposures: No known significant environmental exposures.
2. Immunization HX: The patient is up to date on routine vaccinations, including tetanus and influenza. Inquired about COVID-19 vaccination status; patient confirmed being fully vaccinated with two doses of the Pfizer vaccine in early 2021.

Review of Systems:

General: The patient presents with a general feeling of malaise, likely attributed to persistent lower back pain and recent migraine headaches. No significant weight loss or gain has been reported. The patient denies fever, chills, or night sweats.

HEENT (Head, Eyes, Ears, Nose, Throat): No complaints of vision or hearing impairment. No sinus congestion, postnasal drip, or sore throat was reported. The patient wears prescription eyeglasses for mild myopia.

Neck: No neck pain, stiffness, or swollen lymph nodes were reported. Full range of motion noted.

Lungs: No history of chronic cough, wheezing, or shortness of breath. No chest pain or discomfort was reported.

Cardiovascular: No reported history of chest pain, palpitations, or shortness of breath during exertion. No edema or history of hypertension.

Breast: No breast lumps, pain, or nipple discharge reported. The patient practices monthly breast self-exams and reports no abnormalities.

GI (Gastrointestinal): No history of gastrointestinal bleeding, abdominal pain, or changes in bowel habits. No nausea, vomiting, or diarrhea was reported. Reports regular bowel movements and normal appetite.

Male/Female Genital: No complaints of erectile dysfunction or sexual dysfunction. No history of testicular or ovarian pain. No genital lesions or discharge.

GU (Genitourinary): No urinary frequency, urgency, or dysuria exists. There is no history of kidney stones or urinary tract infections. Reports normal urinary patterns.

Neuro: No history of seizures, loss of consciousness, or neurological deficits. No numbness, tingling, or weakness was reported. Alert and oriented.

Musculoskeletal: As previously mentioned, the patient experiences persistent lower back pain. No joint pain or swelling was reported in other areas of the body. Range of motion is limited in the lumbar region.

Activity & Exercise: Due to lower back pain, the patient has reduced physical activity. Desires to regain normal activity levels after therapy.

Psychosocial: Reports occasional stress due to workload and migraines. Denies symptoms of depression, anxiety, or other mental health issues. Supportive social network.

Derm (Skin): No history of skin rashes, lesions, or itching. No changes in moles or lesions were reported. Wears sunscreen when exposed to the sun.

Nutrition: Maintains a balanced diet and denies significant weight changes. No history of eating disorders. Reports daily consumption of fruits and vegetables.

Sleep/Rest: Reports difficulty sleeping due to migraine headaches. No history of sleep apnea or other sleep disorders. Sleeps an average of 6-7 hours per night.

LMP (Last Menstrual Period): Not applicable for this male patient.

STI Hx (Sexually Transmitted Infections): No history of sexually transmitted infections. Regularly practices safe sex with condom use.

Physical Exam

BP (Blood Pressure): 130/80 mmHg TPR (Temperature, Pulse, Respiratory Rate): Temperature: 98.6°F, Pulse: 78 bpm, Respiratory Rate: 16 breaths/min Ht. (Height): 5 feet 10 inches (70 inches) Wt. (Weight): 175 lbs BMI (percentile): BMI of 25, which falls into the overweight range based on standard BMI classifications.

General: The patient appears to be well-nourished and in no acute distress. No signs of pallor, cyanosis, or jaundice are noted.

HEENT (Head, Eyes, Ears, Nose, Throat):

Head: Normocephalic, atraumatic.

Eyes: Pupils equal, round, and reactive to light (PERRLA). Normal extraocular movements.

Ears: No discharge, tenderness, or hearing loss. Tympanic membranes intact.

Nose: No signs of nasal congestion or epistaxis.

Throat: Moist mucous membranes; no signs of erythema or exudate in the oropharynx.

Neck: No cervical lymphadenopathy, masses, or thyromegaly. Neck has a full range of motion with no pain on movement.

Pulmonary: Lungs are clear to auscultation bilaterally, with no wheezes, rales, or rhonchi. Respiratory effort is regular and unlabored.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Capillary refill is brisk.

Breast: No palpable breast masses or tenderness. No skin changes, dimpling, or nipple discharge noted.

GI (Gastrointestinal):

Abdomen is soft, non-tender, and non-distended.

Normal bowel sounds auscultated in all quadrants.

No hepatosplenomegaly or masses on palpation.

Male/Female Genital: As previously reported in the history section, the patient has no complaints of erectile dysfunction, testicular pain, or genital lesions.

GU (Genitourinary): No suprapubic tenderness or costovertebral angle tenderness noted. No gross hematuria.

Neuro: The patient is alert and oriented. Cranial nerves are intact. Motor and sensory functions are within normal limits. No focal deficits were observed.

Musculoskeletal: As previously reported, the patient experiences limited lumbar range of motion, tenderness over the lumbar region upon palpation, and no signs of inflammation or swelling. No other musculoskeletal issues are noted.

Derm (Skin): No rashes, lesions, or evidence of skin abnormalities observed.

Psychosocial: The patient appears to be in good mental health, alert, and cooperative. He reports occasional stress but denies symptoms of depression or anxiety. He has a supportive social network.

Miscellaneous: No other significant findings during the physical examination.

Plan:

Differential Diagnoses:

Chronic Lower Back Pain:

Lumbar Disc Herniation: Given the patient's history of persistent lower back pain, disc herniation at L4-L5 seen on X-rays may be a leading cause (American Association of Neurological Surgeons, 2019; Johns Hopkins, 2022). That can cause radiating pain and numbness in the lower extremities.

Degenerative Disc Disease: Chronic lower back pain can also result from degenerative changes in the intervertebral discs, leading to reduced disc height and increased friction between vertebrae (Donnally III et al., 2020).

Migraine Headaches:

Migraine with Aura: Frequent migraines with accompanying sensitivity to light and nausea suggest a possible migraine with aura subtype (Mayo Clinic, 2021; Shankar Kikkeri & Nagalli, 2023).

Tension-Type Headaches: As the patient reports persistent stress due to workload, tension-type headaches could be another possible diagnosis (Shah & Hameed, 2020).

Overweight/Obesity-Related Back Pain:

The patient's overweight status, indicated by a BMI in the overweight range, can contribute to mechanical strain on the lumbar spine, potentially exacerbating lower back pain (Whelan, 2023).

Principal Diagnoses:

Chronic Lumbar Disc Herniation:

Based on the X-ray findings and the patient's primary symptom of persistent lower back pain, chronic lumbar disc herniation at L4-L5 is considered the principal diagnosis (American Association of Neurological Surgeons, 2019; Johns Hopkins, 2022). This condition likely contributes significantly to the patient's discomfort and limited mobility.

Migraine Headache Disorder:

Considering the recurring episodes of migraines accompanied by light sensitivity and nausea, a principal diagnosis of migraine headache disorder is warranted (NINDS, 2023; Pescador Ruschel & De Jesus, 2023). The migraines significantly impact the patient's daily life and require attention for management and relief.

Plan

Diagnosis 1 - Chronic Lumbar Disc Herniation:

Diagnostic Testing:

MRI of the Lumbar Spine: To confirm the extent of lumbar disc herniation and assess its impact on nearby structures.

Nerve Conduction Studies: To evaluate any nerve impingement or damage due to the herniated disc.

X-rays: To monitor changes in the spine over time.

Pharmacological Treatment:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Prescribe NSAIDs like ibuprofen to help manage pain and reduce inflammation (American Association of Neurological Surgeons, 2019; Johns Hopkins, 2022). Caution will be taken due to potential gastric issues, given the patient's history.

Muscle Relaxants: If muscle spasms and tension are contributing to the pain, a short course of muscle relaxants may be considered.

Epidural Steroid Injections: In cases of severe pain, epidural steroid injections can be recommended to reduce inflammation around the herniated disc and provide pain relief (Katzung et al., 2021; Whalen, 2018).

Education:

Lifestyle Modifications: The patient will be educated on proper body mechanics, ergonomics, and techniques to prevent exacerbation of the condition.

Physical Therapy: The importance of physical therapy for strengthening and stretching exercises to improve flexibility, posture, and lumbar stability will be emphasized (Katzung et al., 2021; Whalen, 2018).

Medication Adherence: Ensure the patient understands the importance of following the prescribed medication regimen and any potential side effects to watch for.

Activity Modification: The patient will be advised to avoid strenuous activities and heavy lifting until symptoms improve.

Referrals:

Orthopedic Specialist: A referral to an orthopedic specialist for a more comprehensive evaluation and consideration of surgical options, if necessary.

Physical Therapist: Referral to a physical therapist for a customized exercise program.

Pain Management Specialist: If conservative measures are insufficient, consultation with a pain management specialist may be considered for more advanced treatments.

Follow-up:

3-week Follow-up: To assess the patient's response to medication, physical therapy, and lifestyle modifications.

Orthopedic Consultation: Schedule an appointment with the orthopedic specialist within the next four weeks for further evaluation and potential consideration of surgical intervention.

Anticipatory Guidance:

Emphasize the importance of adhering to the treatment plan and recommended lifestyle modifications to manage chronic lumbar disc herniation effectively.

Encourage the patient to maintain a healthy weight through proper diet and exercise to reduce strain on the lumbar spine.

Provide guidance on recognizing signs of worsening symptoms, such as increasing weakness, numbness, or urinary incontinence, and the need to seek immediate medical attention.

Diagnosis 2 - Migraine Headache Disorder:

Diagnostic Testing:

Neuroimaging (CT or MRI): To rule out any structural abnormalities in the brain (NINDS, 2023; Pescador Ruschel & De Jesus, 2023).

Migraine Diary: Instruct the patient to keep a detailed migraine diary to track the frequency, triggers, and response to treatments for migraines.

Pharmacological Treatment:

Acute Migraine Medications: Prescribe triptans (e.g., sumatriptan) for acute migraine relief when needed (Katzung et al., 2021; Whalen, 2018).

Preventive Medications: Consider preventive medications such as beta-blockers, anticonvulsants, or tricyclic antidepressants if the frequency of migraines is significantly impacting the patient's quality of life (Katzung et al., 2021; Whalen, 2018).

Education:

Migraine Triggers: Educate the patient on common migraine triggers, including stress, certain foods, hormonal changes, and the importance of avoiding or managing these triggers (NINDS, 2023; Pescador Ruschel & De Jesus, 2023).

Medication Usage: Explain the proper use of acute and preventive migraine medications, potential side effects, and the importance of following the prescribed regimen.

Lifestyle Modifications: Discuss the benefits of stress management techniques, regular sleep patterns, and a stable daily routine in migraine prevention.

Referrals:

Neurologist: Consider referral to a neurologist for a more specialized evaluation, especially if preventive medications are necessary or if the patient's migraines become more complex.

Follow-up:

4-week Follow-up: To assess the patient's response to migraine management strategies and medications.

Anticipatory Guidance:

Emphasize the importance of maintaining a migraine diary to identify patterns and triggers, which can help with better management.

Advise the patient to stay hydrated, maintain a regular sleep schedule, and manage stress to reduce the frequency and severity of migraines (NINDS, 2023; Pescador Ruschel & De Jesus, 2023).

Encourage open communication about any adverse effects or concerns regarding medications and reassure the patient that various options are available to tailor their treatment plan effectively.

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

American College of Physicians (ACP): ACP provides clinical guidelines on various medical conditions, including musculoskeletal disorders and headaches.

American Academy of Orthopaedic Surgeons (AAOS): AAOS offers evidence-based guidelines for orthopedic conditions, including spine-related issues.

American Migraine Foundation: This foundation may provide information and resources on migraine management based on the latest research and guidelines.

National Institute for Health and Care Excellence (NICE): NICE guidelines are highly regarded for healthcare in the UK, and they often include recommendations for various medical conditions.

The American Headache Society: This organization is dedicated to the study and treatment of headaches, including migraines, and may offer updated guidelines and resources.

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials) J.D. Age 45

Date: 10/30/2023

RX: Ibuprofen 200mg Tablets

SIG: Take 1 tablet by mouth every 6 hours as needed for lower back pain.

Dispense: 30 tablets Refill: 0

No Substitution

Signature: ____________________________________________________________

References

American Association of Neurological Surgeons. (2019). Herniated Disc – Symptoms, Causes, Prevention and Treatments. Aans.org. https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc

Donnally III, C. J., Hanna, A., & Varacallo, M. (2020). Lumbar Degenerative Disk Disease. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448134/

Johns Hopkins. (2022, September 14). Lumbar Disk Disease (Herniated Disk). Www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/health/conditions-and-diseases/lumbar-disc-disease-herniated-disc#:~:text=Lumbar%20disk%20disease%20is%20caused

Katzung, B. G., Kruidering-Hall, M., Tuan, R. L., Vanderah, T. W., & Trevor, A. J. (2021). Katzung & Trevor’s Pharmacology Examination and Board Review, Thirteenth Edition. In Google Books. McGraw Hill Professional. https://www.google.com/books/edition/Katzung_Trevor_s_Pharmacology_Examinatio/UtsPEAAAQBAJ?hl=en

Mayo Clinic. (2021, July 2). Migraine - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201#:~:text=A%20migraine%20is%20a%20headache

NINDS. (2023, January 20). Migraine | National Institute of Neurological Disorders and Stroke. Www.ninds.nih.gov. https://www.ninds.nih.gov/health-information/disorders/migraine

Pescador Ruschel, M. A., & De Jesus, O. (2023, February 13). Migraine Headache. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560787/

Shah, N., & Hameed, S. (2020). Muscle Contraction Tension Headache. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562274/

Shankar Kikkeri, N., & Nagalli, S. (2023). Migraine with Aura. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554611/#:~:text=Galenus%20of%20Pergamon.-

Whalen, K. (2018). Lippincott® Illustrated Reviews: Pharmacology. In Google Books. Wolters kluwer india Pvt Ltd. https://www.google.com/books/edition/Lippincott_Illustrated_Reviews_Pharmacol/8ivvDwAAQBAJ?hl=en&gbpv=1&printsec=frontcover

Whelan, C. (2023, May 25). Back Pain and Obesity: Links, Causes, and Treatments. Healthline. https://www.healthline.com/health/obesity/back-pain-and-obesity#:~:text=Obesity%20is%20a%20common%20condition