PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____

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ICD-10-CM Code: M54.5; Low Back Pain

Patient Name: Ms. Megan Martin

Date of Service: 4/7/17

BACKGROUND INFORMATION:
Referral Source: Dr. Jackson
Referring Diagnosis: LBP
Treatment Requested: Evaluate and treat LBP
Other Referral Information: 45-years-old. Was referred 3 weeks ago. Radiographs of the
lumbar spine and bilateral hips reported normal. DOB: 4/17/72

SUBJECTIVE:
Current condition: Pt complains of bilateral low back pain, primarily on the L side. The
pain wraps around from the L lower back into the pts anterior L thigh. Pt describes the
pain as deep, achy, and dull. Pain is constant and relatively unchanging. Changes in
position provide minimal decrease in pain when the pt side bends to the L side. Pt rates
current pain as 2-3/10 on a visual annual scale. Pain at its best is 2-3/10 and 4-5/10 at its
worst. Insidious onset with no previous history of trauma or low back pain. Tingling and
numbness is absent. The pt works as an accountant and sits at a desk all day, but does not
notice a difference with low back pain by the end of the day. The pt experiences night
pain and reports that it is difficult to find a comfortable position to fall asleep. Pt in a
constant state of general malaise and reports blood in urine, but not in stool. Pt has been
experiencing UTIs once every three months and had one last week. The pt takes an
antibiotic macrobid for 10 days and finds it to be effective until she gets another UTI the
next month. Pt has also had an unexplainable 10 lbs weight loss in the past couple of
months. She started a walking program a year ago and has been walking 30 minutes
5x/week for the past year. The pt states she has not come to PT for 3 weeks since her
referral because it has been difficult to take time off of work and that she has been too
busy. She is a single mother of 3 kids (ages 8, 10, 12). Pt says she has been eating fast
PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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food 2-3x/week when she is busy with driving the kids to sports practices, games, and
extracurricular activities. The doctor has not done any further imaging.
Prior level of function: Pt could perform all ADLs without difficulty. Pt was able to get
through an entire work day without feeling tired.
Current Functional status/activity/participation level: Pt is unable to participate in
physical activity and unable to work a full day without being exhausted.
Patient goals: Pt would like to decrease L lower back pain and to be able to work a full
work day without the feeling of being exhausted.
Employment status/setting: Full-time accountant.
Medical/Surgical history; general health status: No previous surgeries or medical
history. No previous hx of low back pain.
Current medications: 200 mg Ibuprofen; one pill every 2 days
Family health history: Both parents have a hx of heart disease. Mother is a breast cancer
survivor and father had surgery to remove a polyp in his colon.
Social/Cultural history: No hx of smoking or alcohol use.

OBJECTIVE:
EXAMINATION FINDINGS:
Systems Review:
Cardiovascular/Pulmonary: BP: 116/70 mmHg; HR: 88 bpm
Integumentary: Normal in color and warmth bilaterally on low back and thighs.

Observations, Tests and Measures:

General Anthropometric Observations/Posture: Pt comes into the clinic leaning to the L
side in walking, standing, and sitting. Symmetrical PSIS and ASIS in sitting and
standing.

Inspection and Palpation: Areas of pain are not tender to palpation. Pt says the pain feels
deep and does not increase with touch.
PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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Neurological/Sensory: Soft touch normal and present in bilateral UEs, thorax, and LEs.

Joint ROM: Gross trunk and bilateral hip AROM screen is WNL. Pain was unchanging
with movement.

Strength/MMT: Isometric trunk strength WNL with the exception of lumbar flexion
(MMT grade: 3).
L R
4 Hip Extension 5
5 Hip Flexion 5
5 Hip External Rotation 5
5 Hip Internal Rotation 5

Special Tests: Compression (-) for reproduction of symptoms. Distraction (-) for
alleviation of symptoms.

Gait: Pt observed walking into the clinic with side bending to the L.

Functional Mobility, Balance: N/A

Standardized Outcome Assessments: Oswestry Low Back Pain Disability Questionnaire:

16% disability score classified as minimal disability.

INTERVENTIONS:

Discussed recommended interventions, benefits and risks with the pt. They consented to
proceed with initial treatment as described. Pt performed stretches for tight hip flexors
and trunk flexion exercises to try at home (see HEP attachment).
PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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ASSESSMENT:
Summary-Clinical Impressions: Pts subjective and objective findings are inconsistent
with musculoskeletal issues. The pts presentations may be due to underlying visceral
dysfunction and are consistent with kidney referral patterns. The pt did have tight hip
flexors and weakened trunk flexors, which may be due to her altered posture of side
bending to the L.

PT Diagnosis: The pts presentations of low back pain are inconsistent with
musculoskeletal origin. The underlying problem may be due to visceral dysfunction. The
pt has been experiencing recurrent UTIs and blood in the urine. The pts pain is
unchanging with position, constant, achy, and dull. The pt has night pain and has been in
a constant state of general malaise. The pt will need to be referred back to her primary
physician for further testing. The pt also has tight L hip flexors and weakened trunk
flexors due to her L side bending posture.

Prognosis: The pts prognosis for tight L hip flexors and weakened trunk flexors is
moderate. She has stated before that she is very busy and therefore may not adhere to her
HEP. In the meantime, she has been referred back to her primary physician for further
testing in regards to her low back pain.

PROBLEMS:
Body Structure/Function Alterations:
1. L Low Back Pain
2. Tightened L Hip Flexors
3. Weakened Trunk Flexors
Activity Limitations/Participation
Restrictions:
1. Unable to exercise due to her constant
pain
2. Unable to fully extend her hip when
standing up from her chair
3. Unable to sit up in bed without using
hands to bring herself up
PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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GOALS:
Short-term: (1-3 weeks)
1. To be independent in HEP while the patient is waiting to see the doctor before
returning to physical therapy.
2. To decrease tightness of hip flexors in order to be able to extend the hips when
standing up from her chair at work.
3. To increase strength of the trunk flexors from 3/5 to 5/5 in order to stabilize the
lumbar spine in order to maintain proper body mechanics at home.

Long-term: (3-6 weeks)

1. To be able to walk for more than a mile without pain in order to resume
walking program of 30 minutes 5x/week.
2. Decrease Oswestry Low Back Pain Disability Questionnaire from the score of
16% to 8%

PLAN OF CARE:
The patient is going to refer back to her primary physician before returning to physical
therapy. The patient is to be independent in the HEP plan given to her, which will aim to
strengthen her core and stretch her hip flexors. Once she returns with more information
from her doctor, we will reassess her low back pain.

___Sierra Moore______ SPT

PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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ATTACHMENTS:
Home Exercise Plan:
1. Hip Flexor Stretch in Kneeling
2 sets of 60 second holds. Perform every day after work.

2. Hip Flexor Stretch in Supine

Hold one time for 120 seconds before bed every night.
PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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3. Trunk Flexion Exercise with Red Band

3 sets of 10-12 with a minute break in between sets if needed. Perform 5x every
week.

4. Bicycle Crunch
2 sets of 20 with Red Band. Perform 5x/week.
PTH 633 SOAP Note Template THERAPIST NAME: _Sierra Moore_____
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Matsuo, S., Suzuki, S., Iwata, M., Banno, Y., Asai, Y., Tsuchida, W., & Inoue, T. (2013).
Journal of Strength and Conditioning Research, 27 (12), pp. 3367-3376.