Advanced Health Assessment Week 8 Focus/ Episodic SOAP Note Musculoskeletal Case Study 1

Advanced Health Assessment Week 8 Focus/
Episodic SOAP Note Musculoskeletal Case Study 1
SUBJECTIVE DATA
Chief Complaint:
“I have been having pain in my lower back for a month now. Sometimes it feels like a
sharp painshooting down the back of my leg and other times I feel like it is numb and
tingling. I never had this pain until after doing yard work all day.
History of Present Illness (HPI):
Mr. John Doe is a 42-year-old Caucasian male that presents to the clinic today with
complaints oflow back pain with intermittent periods of sharp, shooting pains down the
posterior left leg and periods of numbness and tingling that began one month ago. He
rates his pain as a 7 on a pain scale of 1-10. He reports that his pain seems to be worse
if he sits down too long or twist his back. Reports pain if relieved when he stands up
and walks around and pain is also alleviated if he lays flat on his back with a pillow
under his knees.
Medications:
• One a Day Men’s Health Multivitamin PO daily
Allergies:
Denies drug, food, environmental, or latex allergies.