SOAP Note for Chronic Lower Back Pain
SUBJECTIVE
CC: C.N. is a 72 year old white Male well known patient complaining of chronic
lower back pain.
HPI: C.N is 72 year old white male presenting with complaint of chronic lower
back pain rates pain 6/10 scale presently. C.N states onset started six weeks ago
and has been constant in lower back and radiates towards hips. Describes pain as a
throbbing dull ache that lasts for 45 mins – a couple of hours depending on his
activity. Pain is worse with activity 9/10 and decreases to 2/10 with rest. Pain is
also worse at night preventing him from sleeping well. He has been taking Aleve,
Tylenol, and using CBD cream with little relief. He states he fell approximately six
weeks ago on ice and hit his lower back on the curb. He states he had some
bruising three days after the incident but has disappeared but pain has not gotten
any better. He is having difficulty getting in/out of car and has had to leave his
grandkids ball games early on multiple occasions.
PMH: Migraines, Hypothyroidism, Chronic sinusitis, Arthritis.
FH: Father unknown. Mother- Hypothyroidism, Hypertension, Depression.
Maternal Grandparents both deceased MVA.
SH: Widowed 2015.Has 2 daughters. Office manager part time for MFA.
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, Nonsmoker, denies street drugs, occasional wine less than 6 drinks per month.
Hobbies- horses, gardening, and bible study.
Meds: Amerge 2.5mg po one max 2 in 24 hrs for migraines. Claritin 10mg one po
daily during allergy season, Arthritis Tylenol 650mg one-two every 6 hrs not to
exceed 3000mg in 24 hrs prn pain, Aleve 220mg one po every 12 hrs prn pain,
CBD cream OTC apply topically prn, Synthroid 50mcg one po daily.
Allergies: Biaxin- heart palpitations, Flu vaccine- anaphylaxis
Immunizations: Up to date with MMR,DTAP,TETANUS,HEP B SERIES, unable
to take Flu vaccine
ROS:
General- AXOX 3, uncomfortable on exam table, negative for weight loss.
Skin- DENIES Rashes Itching
Head- DENIES Headache Head injury or Vertigo
Eyes- DENIES Pain Redness Blurry or double vision. GLASSES no CONTACTS
Ears- DENIES Earache , tinnitus, or drainage
Nose- DENIES Stuffiness Itching Nosebleeds Discharge Hay fever OR Sinus pain
Mouth/Throat- DENIES Teeth Gums Bleeding, DENIES Sore tongue ,Dry mouth,
Sore throat Hoarseness, OR Thrush
Neck- DENIES Lumps Pain Swollen glands Stiffness OR Limitation of movement
Breasts- denies tenderness or lumps.
This study source was downloaded by 100000869267694 from CourseHero.com on 08-02-2023 15:52:22 GMT -05:00
https://www.coursehero.com/file/55689625/soap-note-back-paindocx/
SUBJECTIVE
CC: C.N. is a 72 year old white Male well known patient complaining of chronic
lower back pain.
HPI: C.N is 72 year old white male presenting with complaint of chronic lower
back pain rates pain 6/10 scale presently. C.N states onset started six weeks ago
and has been constant in lower back and radiates towards hips. Describes pain as a
throbbing dull ache that lasts for 45 mins – a couple of hours depending on his
activity. Pain is worse with activity 9/10 and decreases to 2/10 with rest. Pain is
also worse at night preventing him from sleeping well. He has been taking Aleve,
Tylenol, and using CBD cream with little relief. He states he fell approximately six
weeks ago on ice and hit his lower back on the curb. He states he had some
bruising three days after the incident but has disappeared but pain has not gotten
any better. He is having difficulty getting in/out of car and has had to leave his
grandkids ball games early on multiple occasions.
PMH: Migraines, Hypothyroidism, Chronic sinusitis, Arthritis.
FH: Father unknown. Mother- Hypothyroidism, Hypertension, Depression.
Maternal Grandparents both deceased MVA.
SH: Widowed 2015.Has 2 daughters. Office manager part time for MFA.
This study source was downloaded by 100000869267694 from CourseHero.com on 08-02-2023 15:52:22 GMT -05:00
https://www.coursehero.com/file/55689625/soap-note-back-paindocx/
, Nonsmoker, denies street drugs, occasional wine less than 6 drinks per month.
Hobbies- horses, gardening, and bible study.
Meds: Amerge 2.5mg po one max 2 in 24 hrs for migraines. Claritin 10mg one po
daily during allergy season, Arthritis Tylenol 650mg one-two every 6 hrs not to
exceed 3000mg in 24 hrs prn pain, Aleve 220mg one po every 12 hrs prn pain,
CBD cream OTC apply topically prn, Synthroid 50mcg one po daily.
Allergies: Biaxin- heart palpitations, Flu vaccine- anaphylaxis
Immunizations: Up to date with MMR,DTAP,TETANUS,HEP B SERIES, unable
to take Flu vaccine
ROS:
General- AXOX 3, uncomfortable on exam table, negative for weight loss.
Skin- DENIES Rashes Itching
Head- DENIES Headache Head injury or Vertigo
Eyes- DENIES Pain Redness Blurry or double vision. GLASSES no CONTACTS
Ears- DENIES Earache , tinnitus, or drainage
Nose- DENIES Stuffiness Itching Nosebleeds Discharge Hay fever OR Sinus pain
Mouth/Throat- DENIES Teeth Gums Bleeding, DENIES Sore tongue ,Dry mouth,
Sore throat Hoarseness, OR Thrush
Neck- DENIES Lumps Pain Swollen glands Stiffness OR Limitation of movement
Breasts- denies tenderness or lumps.
This study source was downloaded by 100000869267694 from CourseHero.com on 08-02-2023 15:52:22 GMT -05:00
https://www.coursehero.com/file/55689625/soap-note-back-paindocx/
