SOAP Note Week 3 NU610: Answered Latest Spring 2026_ Herzing University.

SOAP Note Week 3 Name:__Amanda Bright______
Typhon Encounter #: _____________________
NU610:_____ Comprehensive:____Focused:____
Herzing University

S: SUBJECTIVE DATA
CC: “I hurt my back pulling bushes, now pain goes down my left leg.”

HPI: This is a 35-year-old male who presents with the acute onset of low back
pain that began while pulling large bushes during yard work earlier today.
The pain is located in the lower back and radiates down the posterior
aspect of the left leg. He describes the pain as sharp and “lightning-like”
in quality, rating it 8/10 in severity. Since onset, the pain has
progressively worsened, and he reports significant difficulty bearing
weight on the affected leg. The pain is aggravated by active leg movement
and weight bearing, while passive leg movement causes only minimal
discomfort. He obtained slight relief after taking 800 mg of ibuprofen
initially but has not taken any further medication. He denies prior history
of low back pain or trauma. Associated symptoms are absent, as he denies
fever, chills, headaches, dizziness, rashes, unexplained weight changes,
bowel or bladder dysfunction, or saddle anesthesia.
PMH: This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.

ALLERGIES No known drug or food allergies.

MEDICATIONS Initially took 800 mg of ibuprofen but is no longer

SH  Divorced; shares custody of three children.
 Works IT from home; sedentary ~8 hours/day.
 Runs 30 min daily; eats “healthy.”
 Tobacco: quit cigarettes 5 years ago (10 pack-years); currently
vapes daily.
 Alcohol: 1 beer with dinner nightly.
 Denies illicit drugs.
 No routine preventive care.
FH  No family history of spine, musculoskeletal disease, or
malignancy.
HEALTH Required for all SOAP notes:
PROMOTION &  Exercise: runs daily.
MAINTENANC  Nutrition: generally a healthy diet.
E  Immunizations: status unclear; to review/update.
 Preventive care: does not receive regular checkups.
 USPSTF: Age-appropriate screenings indicated (lipids, diabetes if
overweight, HIV, Hep C, BP, depression, tobacco/alcohol
counseling, vaccines).
CDC Adult Immunization Recommendations (Age 19–59; patient age

, SOAP Note Week 3 Name:__Amanda Bright______
Typhon Encounter #: _____________________
NU610:_____ Comprehensive:____Focused:____
Herzing University

35):
 Influenza: Educated on risk and benefits patient refused
 Tdap/Td: last received Date Unknown, educated on risk and
benefits patient refused
 COVID-19: Educated on risk and benefits, patient refused
Hepatitis B: previously immune status not known
 Hepatitis A: Not recommended
 MMR: previously immune status not known, would recommend
having titters done
 Varicella: previously immune status not known, recommend
having titters done
 HPV: Educated on risk and benefits patient refused
 Meningococcal: Educated on risk and benefits patient refused
 Meningococcal B: Not recommended
 Pneumococcal (PCV15/20, PPSV23): Not recommended
 Zoster (Shingles): Start at age 50. Not recommended

Preventive Services (USPSTF Recommendations):

Screening / Intervention Recommendation
Blood Pressure Screen: normal today.
Obesity (BMI) Screen all adults.
Tobacco Use/Vaping Counsel, offer cessation.
Alcohol Use Screen, brief counseling.
Depression Screen adults ≥18.
Anxiety Screen <65.
Diabetes Screen 35–70 if overweight/obese.
Lipids Screen men ≥35.
HIV One-time screen 15–65.
Hepatitis C Screen 18–79.
STIs Screen if at risk.
Colorectal CA Begin at 45 (not indicated).
Lung CA 50–80 w/ ≥20 pack-years (not indicated).

Lifestyle & Counseling:
 Diet: Encourage healthier options; reduce processed foods and sugary
beverages
 Exercise: Encourage structured activity as feasible
 Safety: Continue seatbelt use and protective measures at work/home
 Tobacco: Discuss smoking cessation options
 Alcohol & substance use: Continue to avoid