Sample "Soap Note"

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Patient Name ________________ Examinee Label_______________________
SOAP NOTE
Do Not write on opposite side of page
Comments
Case __________ Examinee Name________________
Date________
S cc: 35 yo Caucasian male presents with low back pain x 2 days.
Hxcc: Patient was shoveling snow when pain started in the low back on the right side. Pain started at
SOAP NOTE
an 8/10 and now is a 6/10 pain described as tight and constant. Activity makes pain worse, nothing
makes it better. Patient has taken Motrin and used a heating pad since onset. Patient denies any
numbness, tingling, burning pain, or pain that radiates down either leg, also denies any previous low
back trauma or pain.
HTN – Controlled with Metoprolol.
PMH:
PSH:
None
Meds:
Metoprolol for HTN.
Allergies: NKDA
FH:
Mother arrhythmia and CAD, Father CAD.
SH:
Smoked 15 years ago, unknown pack years. 3 glasses of wine/week.
Bank Teller.
ROS:
General: Denies change in weight, fatigue, insomnia
CV: Denies chest pain, irregular heartbeat, rapid heart beat
Score__/_
Resp: Denies shortness of breath, dyspnea on exertion, cough, orthopnea
GI: Denies nausea, vomiting, constipation, diarrhea, heartburn
Musculoskeletal: denies recent fractures, sprains, strains, limited use of any joint
Neurological: Denies seizures, tremors, numbness or tingling
O
VS: T 98.5º F, BP 129/80, R 14, P 72
Gen:
Minimal distress. Alert and oriented to person, place, and time.
Pleasant Affect.
Heart:
RRR, no murmurs, gallops, or rubs.
Lungs:
CTA in all 6 lung fields.
Neuro: Lower Extremity Strength 5/5 and symmetric. Lower extremity reflexes +2/4, symmetric at
patella and Achilles.
Musculoskeletal: Gait with hip hike on left heel strike. Moderate tenderness at right L5 and sacroiliac
Score__/__
junction. Negative straight leg test. R upper lumbar hypertonicity. Decreased ROM to trunk flexion.
_
+ R standing flexion test, – seated flexion test. L5FRSright. R anterior innominate.
A.
(Diagnosis and/or problem list)
P.
1. Low back strain
1. Ibuprofen, PRN
2. Somatic Dysfunction
2. OMT utilizing Muscle Energy to
- Lumbar, Pelvis
Pelvis - Pt tolerated Tx well with
3. HTN – Controlled with Meds
decreased pain and improved
structural findings
3. F/U in 2 days and call if worsening
symptoms
Score__/__
Patient Name ________________ Examinee Label_______________________
SOAP NOTE
Do Not write on opposite side of page
Comments
Case __________ Examinee Name________________
Date________
S cc: 35 yo Caucasian male presents with low back pain x 2 days.
Hxcc: Patient was shoveling snow when pain started in the low back on the right side. Pain started at
SOAP NOTE
an 8/10 and now is a 6/10 pain described as tight and constant. Activity makes pain worse, nothing
makes it better. Patient has taken Motrin and used a heating pad since onset. Patient denies any
numbness, tingling, burning pain, or pain that radiates down either leg, also denies any previous low
back trauma or pain.
HTN – Controlled with Metoprolol.
PMH:
PSH:
None
Meds:
Metoprolol for HTN.
Allergies: NKDA
FH:
Mother arrhythmia and CAD, Father CAD.
SH:
Smoked 15 years ago, unknown pack years. 3 glasses of wine/week.
Bank Teller.
ROS:
General: Denies change in weight, fatigue, insomnia
CV: Denies chest pain, irregular heartbeat, rapid heart beat
Score__/_
Resp: Denies shortness of breath, dyspnea on exertion, cough, orthopnea
GI: Denies nausea, vomiting, constipation, diarrhea, heartburn
Musculoskeletal: denies recent fractures, sprains, strains, limited use of any joint
Neurological: Denies seizures, tremors, numbness or tingling
O
VS: T 98.5º F, BP 129/80, R 14, P 72
Gen:
Minimal distress. Alert and oriented to person, place, and time.
Pleasant Affect.
Heart:
RRR, no murmurs, gallops, or rubs.
Lungs:
CTA in all 6 lung fields.
Neuro: Lower Extremity Strength 5/5 and symmetric. Lower extremity reflexes +2/4, symmetric at
patella and Achilles.
Musculoskeletal: Gait with hip hike on left heel strike. Moderate tenderness at right L5 and sacroiliac
Score__/__
junction. Negative straight leg test. R upper lumbar hypertonicity. Decreased ROM to trunk flexion.
_
+ R standing flexion test, – seated flexion test. L5FRSright. R anterior innominate.
A.
(Diagnosis and/or problem list)
P.
1. Low back strain
1. Ibuprofen, PRN
2. Somatic Dysfunction
2. OMT utilizing Muscle Energy to
- Lumbar, Pelvis
Pelvis - Pt tolerated Tx well with
3. HTN – Controlled with Meds
decreased pain and improved
structural findings
3. F/U in 2 days and call if worsening
symptoms
Score__/__