SOAP Note 3 Name:_
_ Typhon Encounter #:
NU 610:7G Comprehensive:
Herzing University
S: SUBJECTIVE DATA
CC: Acute onset of low back pain.
HPI: The patient is a 35-year-old male who presents with acute onset of low
back pain while pulling bushes during yard work. The patient reports
lower back pain with radiation down the back of the left leg. The pain has
worsened in intensity since the initial injury, and he is having difficulty
bearing weight on the left leg. Pain is described as sharp, lightning-like
pain. Pain is aggravated by weight-bearing on the left leg and active
movement of the lower extremity. The patient reports minimal relief with
800mg ibuprofen taken initially and has not taken any other medications.
Severe pain is reported with active lower extremity moment, minimal pain
with passive movement, and positive straight leg raise. Pain rated 8 out of
10.
PMH: No significant past medical history reported.
ALLERGIES None reported
MEDICATIONS Ibuprofen OTC. – pt took 800mg ibuprofen after initial injury
SH Recently divorced, shares custody of three children. The patient smoked
one pack/day for 10 years; he reports quitting 5 years ago but vapes
daily. Drinks one beer daily with dinner. Denies any illicit drug use.
Works in IT and sits for 8 hours per day. Reports running 30 minutes
daily and diet described as “healthy.”
FH Denies familial history of spine or musculoskeletal disorders or
malignancy.
HEALTH Required for all SOAP notes: The patient does not get regular health
PROMOTION & maintenance. Reports he only sees his primary care provider when he has
MAINTENANC an acute issue.
E
ROS Constitutional Denies fever, chills, weight loss,
or weight gain
(put N/A in sections Head Denies headache
not completed day of
exam) Eyes N/A
Ears, Nose, Mouth, Throat N/A
Neck N/A
Cardiovascular/Peripheral N/A
Vascular
Respiratory N/A
, SOAP Note 3 Name:_
_ Typhon Encounter #:
NU 610:7G Comprehensive:
Herzing University
Breast N/A
Gastrointestinal Denies loss of bowel control or
saddle anesthesia
Genitourinary Denies loss of bladder control or
saddle anesthesia
Musculoskeletal Reports severe pain in the lower
back that radiates to the left leg.
Denies any history of similar pain
or injuries.
Integumentary Denies rashes or bruising
Neurological Denies headaches, dizziness,
saddle anesthesia, or other
neurological deficits apart from
the pain.
Psychiatric (screening tools: Ex: N/A
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic N/A
Other N/A
O: OBJECTIVE DATA
VITALS: HR: 79 RR: 16 BP: 124/78 Temp: 97.3
SpO2%: 100% Ht: N/A Wt: N/A BMI: N/A
RA
Age: 35 LMP: N/A PAIN: 8/10
PHYSICAL General Appearance Appears in acute distress
EXAM related to pain
Head N/A
(Pertinent data Eyes N/A
related to
ENT, Mouth N/A
presenting
problem or Neck N/A
visit type. Put Cardiovascular/Peripheral Vascular Regular rate and rhythm, no
N/A in murmurs, rubs, or gallops
sections not
Respiratory Bilateral lung sounds clear to
completed day
of exam) auscultation, no adventitious
breath sounds noted.
_ Typhon Encounter #:
NU 610:7G Comprehensive:
Herzing University
S: SUBJECTIVE DATA
CC: Acute onset of low back pain.
HPI: The patient is a 35-year-old male who presents with acute onset of low
back pain while pulling bushes during yard work. The patient reports
lower back pain with radiation down the back of the left leg. The pain has
worsened in intensity since the initial injury, and he is having difficulty
bearing weight on the left leg. Pain is described as sharp, lightning-like
pain. Pain is aggravated by weight-bearing on the left leg and active
movement of the lower extremity. The patient reports minimal relief with
800mg ibuprofen taken initially and has not taken any other medications.
Severe pain is reported with active lower extremity moment, minimal pain
with passive movement, and positive straight leg raise. Pain rated 8 out of
10.
PMH: No significant past medical history reported.
ALLERGIES None reported
MEDICATIONS Ibuprofen OTC. – pt took 800mg ibuprofen after initial injury
SH Recently divorced, shares custody of three children. The patient smoked
one pack/day for 10 years; he reports quitting 5 years ago but vapes
daily. Drinks one beer daily with dinner. Denies any illicit drug use.
Works in IT and sits for 8 hours per day. Reports running 30 minutes
daily and diet described as “healthy.”
FH Denies familial history of spine or musculoskeletal disorders or
malignancy.
HEALTH Required for all SOAP notes: The patient does not get regular health
PROMOTION & maintenance. Reports he only sees his primary care provider when he has
MAINTENANC an acute issue.
E
ROS Constitutional Denies fever, chills, weight loss,
or weight gain
(put N/A in sections Head Denies headache
not completed day of
exam) Eyes N/A
Ears, Nose, Mouth, Throat N/A
Neck N/A
Cardiovascular/Peripheral N/A
Vascular
Respiratory N/A
, SOAP Note 3 Name:_
_ Typhon Encounter #:
NU 610:7G Comprehensive:
Herzing University
Breast N/A
Gastrointestinal Denies loss of bowel control or
saddle anesthesia
Genitourinary Denies loss of bladder control or
saddle anesthesia
Musculoskeletal Reports severe pain in the lower
back that radiates to the left leg.
Denies any history of similar pain
or injuries.
Integumentary Denies rashes or bruising
Neurological Denies headaches, dizziness,
saddle anesthesia, or other
neurological deficits apart from
the pain.
Psychiatric (screening tools: Ex: N/A
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic N/A
Other N/A
O: OBJECTIVE DATA
VITALS: HR: 79 RR: 16 BP: 124/78 Temp: 97.3
SpO2%: 100% Ht: N/A Wt: N/A BMI: N/A
RA
Age: 35 LMP: N/A PAIN: 8/10
PHYSICAL General Appearance Appears in acute distress
EXAM related to pain
Head N/A
(Pertinent data Eyes N/A
related to
ENT, Mouth N/A
presenting
problem or Neck N/A
visit type. Put Cardiovascular/Peripheral Vascular Regular rate and rhythm, no
N/A in murmurs, rubs, or gallops
sections not
Respiratory Bilateral lung sounds clear to
completed day
of exam) auscultation, no adventitious
breath sounds noted.
