MUSCULOSKELETOL

Episodic/Focused SOAP: Musculoskeletal

Student’s Name
Course
Date

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 Episodic/Focused SOAP: Musculoskeletal

Focused SOAP Note for a patient with low back pain.

S.
CC: “low back pain” 

HPI: The patient is 42 years old, experiences lower back pain which began a month ago. The
pain is dull and achy, experiences sharp pain on his left leg. The pain becomes severe at night.
He feels a burning sensation on the left buttock and tingling and numbness in the left foot. He
has tried ibuprofen tablet with no relief.
Current Medications: Lisinopril 40mg tablet daily, Lipitor 40mg bedtime, ibuprofen 200mg.
PMH: HTN and hyperlipidemia, Tdap vaccine 2106, Flu Vaccine.

FH: Mother, age 73, hyperlipemia, Father age 75, HTN, Brother age 45, HTN, Grandparents
type of death unknown. Has 3 Children.
SH: Denies tobacco abuse and use of illicit drugs, currently or previously; consumes moderate
alcohol; married for 15 years 

ROS   
General—Fever, chills, lower back pain, signs of weakness and fatigue.
Cardiovascular—History of Hyperlipidemia and HTN, denies chest pain, denies palpitations.
Gastrointestinal--Positive for nausea without vomiting; negative for diarrhea, abdominal pain.
Respiratory: Breathing is normal, no cough or sputum.
Neurological: Numbness and tingling in foot and left leg denies dizziness,
Genitourinary: No changes in urinary patterns, no difficulties in passing urine,
Musculoskeletal: Lower back pain radiating towards the left leg.
O

VS: BP 155/83; Pain 8/10; R 22; T 98.4F; 02 96% Wt 255lbs; Ht 5”10” Rr 19nlbs

General—Appears to be in acute distress, Normal gait, well nourished, well-groomed AAO x 4

HEENT: Clear tympanic membranes, hearing intact, external appearance normal, no lesions, no
inflammations,
Neck: Normal Carotids, bilateral pulse, jugular vein distention.
Chest/lungs: No crepitus, rhonchi, or cough noted.
Cardiovascular—Normal gait, Cranial nerves II-XII intact, reflexes 2+ symmetric.
Musculoskeletal: Normal cervical, thoracic and lumbar curves, Normal gait, lateral bending,
right rotation, left rotation, uptight spinal column, full range of motion in all joints, radiation, no
deformities, no swelling, skin creases below the buttock, left gear toe and all metatarsals on feet,
Positive Monofilament to right and left.
Integumentary: Good skin turgor, warm, supple.

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MUSCULOSKELETOL

Diagnostic results:

1. Radiculopathy
Condition cause by a compressed nerve in the spine. It results to numbness, tingling, pain and
weakness on the course of the nerve. It is common in lumbar radiculopathy (lower back) and the
cervical radiculopathy symptoms range from mild to severe (Giorgi, 2021).

A.
Differential Diagnosis:
2.Degenerative Disc disease- Wear and tear of spinal disc causes hot shooting pians. Pain is
moderate to severe. Degenerative disc is associated with old age (McHugh, 2017). This condition
is probable based in the symptoms.

3. Spinal stenosis- This is the narrowing of the bone channel when occupied by spinal nerves. It
may lead to intermittent pain which can radiate the legs. Symptoms include canal narrowing. The
pain can worsen when standing or walking (Benjamin,2019). These symptoms do not fit our
patient.
4. Lumber herniated disc: Back or leg pian may be caused by the rapture of gel-like center of
lumber through the outer wall. Pain radiates from the back to both legs. Sitting, bending or
twisting may increase the pain (Bohinski, 2021). The patient fits these symptoms.
5.Mechanical low back pains: Pain arises intrinsically from the intervertebral discs, spine or
soft tissues. It radiates to thigh and buttocks, pain experienced during lifting heavy objects,
flexion of the back and poor conditioning (Hill, 2021). These symptoms fit our patient.

Diagnostics tests
MRI to detect the type of disc damaged, overgrowth, nerve compression or spinal cord tumors,
X-rays: Detect bone spurs and fractures, arthritic changes.
CT scan: To detect lumbar disc damage
EMG $ NCS: To detect nerve damage, electrical activities of the muscles.
CBC and Sed rate: Not necessarily required by help to check for white blood count, infections.

P. This section is not required for the assignments in this course (NURS 6512) but will be
required for future courses.

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 References
Bohinski, R. (2021). Herniated lumbar Disc, herniated disc, ruptured lumbar disc, bulging disc
back surgery, | Mayfield Brain & Spine. Mayfieldclinic.com. Retrieved 19 January 2021,
from
https://mayfieldclinic.com/pe-hldisc.htm.

Benjamin Bjerke, M. (2019). What Is Spinal Stenosis? Spine-health. Retrieved 19 January 2021,

from https://www.spine-health.com/conditions/spinal-stenosis/what-spinal-stenosis.

Brian McHugh, M. (2017). What Is Degenerative Disc Disease? Spine-health. Retrieved 19

January 2021, from https://www.spine-health.com/conditions/degenerative-disc-
disease/what-degenerative-disc-disease.

Hill, E. (2021). Mechanical Low Back Pain: Practice Essentials, Background, Pathophysiology.

Emedicine.medscape.com. Retrieved 19 January 2021, from
https://emedicine.medscape.com/article/310353-
overview#a5https://emedicine.medscape.com/article/310353-overview#a5.

Giorgi, A. (2021). Radiculopathy | Definition and Patient Education. Healthline. Retrieved 19

January 2021, from https://www.healthline.com/health/radiculopathy.

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