Walden University Musculoskeletal SOAP Note

35 y/o Caucasian male presents with low back pain x 2 days. The patient was lifting weight at work when the pain started in the low back on the right side. The pain started at an 8/10 and now is a 6/10 pain described as tight and constant. The activity makes the pain worse, nothing makes it better. The patient has taken Motrin and used a heating pad since onset. The patient denies any numbness, tingling, burning pain, or pain that radiates down either leg, also denies any previous low back trauma or pain.

Your week 9 SOAP is musculoskeletal/ It is a focused note and you will NEED to do a physical exam on the patient and a COMPLETE exam of the MS system that includes two specific musculoskeletal assessment tests and include that in your assessment. TWO specific exams for your musculoskeletal patient! Every advanced assessment by a provider should contain system-specific exams.

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently in a similar patient evaluation?