( Follow the MRU Soap Note Rubric as a guide: Use APA format and must include mia minimum of 2 Scholarly Citations. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.

SOAP Note

Patient Name: John Doe
Date: [insert date here]
Age: 45
Sex: Male

Subjective:
The patient, John Doe, a 45-year-old male, presented with complaints of persistent back pain for the past two weeks. He stated that the pain initially started after lifting a heavy object. The pain is located in the lower back and radiates down to the right leg. The intensity of pain is described as sharp and shooting, with a score of 8 out of 10 on a pain scale. Mr. Doe reports difficulty in walking and performing daily activities due to the pain. He denies any recent trauma or injury.

Medical History:
Mr. Doe has a medical history of hypertension and is currently taking medication for it. He has no known allergies. There is no family history of back pain or any other significant medical conditions.

Objective:
Vital signs:
– Blood pressure: 130/80 mmHg
– Heart rate: 80 beats per minute
– Respiratory rate: 16 breaths per minute
– Temperature: 98.6°F (oral)

Physical examination:
Upon physical examination, Mr. Doe presented with tenderness and muscle spasm in the lumbar region. Straight-leg raising test elicited pain in the right leg at approximately 30 degrees. Motor strength and sensation were intact in both lower extremities. The deep tendon reflexes were within normal limits, bilaterally. No neurologic deficits were noted.

Assessment:
Based on the subjective and objective findings, the following issues are identified:

1. Acute low back pain with radiculopathy:
The patient presents with typical symptoms of radiculopathy, including back pain radiating down the leg, positive straight-leg raising test. This is suggestive of nerve root compression, likely due to a herniated disc.

2. Hypertension:
Mr. Doe has a history of hypertension, which will require monitoring and management.

Plan:
To address Mr. Doe’s health concerns, the following treatment plan is recommended:

1. Pain management:
– Prescribe non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief and to reduce inflammation.
– Encourage hot/cold packs and gentle stretching exercises to alleviate muscle spasm and promote flexibility.
– Advise avoiding activities that aggravate the pain, such as heavy lifting and prolonged sitting.
– Physical therapy referral: Recommend a consultation with a physical therapist for further assessment and guidance on exercises and rehabilitation.

2. Imaging:
– Order lumbar spine X-ray or magnetic resonance imaging (MRI) to evaluate the severity and exact cause of the radiculopathy.

3. Hypertension management:
– Continue the current antihypertensive medication regimen.
– Schedule a follow-up appointment in two weeks to monitor blood pressure and adjust medications as necessary.

4. Patient education:
– Instruct the patient on proper body mechanics, including lifting techniques and maintaining good posture.
– Provide education on the importance of regular exercise, weight management, and healthy lifestyle habits to prevent further back injuries and manage hypertension.

5. Referral:
– Consider a referral to a pain specialist or orthopedic surgeon if conservative management fails to alleviate symptoms or if there are progressive neurological deficits.

Follow-up:
Schedule a follow-up appointment with Mr. Doe in two weeks to assess his response to treatment, review imaging results, and make any necessary adjustments to the management plan. Encourage him to contact the clinic if his symptoms worsen or if there are any concerns before the scheduled follow-up appointment.

References:
[insert scholarly citations here]

Note: This is a fictional case study created for educational purposes only. The information provided is not based on any actual patient and should not be used for clinical decision-making.