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NU610 Unit 3 Case Study
A 35-year-old male presents with the onset of acute low back pain. He was doing some yard work,
May 31, 2025
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Bam soap week 3
Casestudy.docx
2
NU610 Unit 3 Case Study
A 35-year-old male presents with the onset of acute low back pain. He was doing some yard work, including pulling out large bushes, when he experienced the acute onset of low back pain, radiating down the back of the left leg. Since then, the pain has worsened in intensity, and he is having difficulty bearing weight on the leg. He initially took 800 mg ibuprofen, which provided a small degree of relief, but he has not taken any medication since the problem initially occurred. The patient has no significant medical history. His general physical examination is within normal limits with regards to cardiovascular and pulmonary system. On neurological examination, he has severe pain with active movement of the lower extremity, but only minimal pain with passive movement of the lower extremity. He has a positive straight leg raise but no other neurological deficits. Denies loss of bowel or bladder or saddle anesthesia. Denies fever, chills, weight loss or weight gain. Denies headaches, dizziness, rashes or bruising. Denies history of lower back pain or previous injury to back. He is recently divorce and shares custody of three children. He reports smoking about 1 pack of cigarettes a day for 10 years but quit 5 years ago, currently vapes daily. He reports one beer with dinner, denies illicit drug use. Denies hospitalizations or surgical history. He does not get regular health maintenance and only sees primary care provider when has acute issue. He works for IT department from home and sits about 8 hours per day. He reports running at least 30 minutes daily and overall eats “healthy.” Denies family history of spine or musculoskeletal diseases or malignancy. VS in office BP 124/78, HR 79, RR 16, Temp 97.3, 100% on RA. Appears in acute distress related to pain. Rates pain 8 out of 10, described as sharp, lightening sensation.
SOAPNoteTemplate-Final28129.docx
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC:
What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI:
Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH:
This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
ALLERGIES
State the offending medication/food and the reactions.
MEDICATIONS
Names, dosages, and routes of administration along with indication of use.
SH
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
FH
Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.
HEALTH PROMOTION & MAINTENANCE
Required for all SOAP notes:
Immunizations, exercise, diet, etc. Remember to use the
United States Clinical Preventative Services Task Force (USPSTF)
for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.
ROS
(put N/A in sections not completed day of exam)
Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
VITALS:
HR:
RR:
BP:
Temp:
SpO2%:
Ht:
Wt:
BMI:
Age:
LMP:
PAIN:
PHYSICAL EXAM
(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)
General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
· External Exam
· Internal Exam
Genitourinary Female
· External Exam
· Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS
ICD-10 CODES
PRIORITIZE DIAGNOSIS
1.
2.
3.
VISIT CODES
CPT BILLING CODES
DIAGNOSTICS
POC TESTING
TESTS REVIEWED
P: PLAN
ACTIONS
1.
Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)
Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
2.
Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3.
Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.
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