Lumbar Strain SOAP Note Sample Report
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is a (XX)-year-old woman who presents to the clinic for complaints of lumbar pain. The patient states this has been going on for approximately one week. She is unable to identify any precursors to the pain. She states that she is having the pain every day.
Sometimes, it starts in the morning when she first gets up and she has difficulty getting out of bed. Other times, she notices it as the day goes on. She does report, however, that the pain does tend to improve when she uses her heating pad on it, and she said she has taken ibuprofen once or twice and that seemed to help, but she did not feel comfortable taking ibuprofen consistently because she was concerned about its effect on her kidney even though she has not been taking it in excess.
PAST MEDICAL HISTORY: Significant for dysmenorrhea, intermittent GERD, and hyperlipidemia. She has also had knee pain and a recent finger sprain and a history of thrombophlebitis.
ALLERGIES: She has no known drug allergies.
MEDICATIONS: She is not taking any medication on a regular basis at this point in time.
OBJECTIVE: The patient’s blood pressure is 132/80. Her heart rate is 80 and regular. Lung sounds are clear. Respirations are 14. Lumbar spine is symmetrical. She is able to lie supine on the exam table, but she does so carefully. Bilateral straight leg raise is negative. She is able to bend from the waist to about 60 degrees and then she does complain of bilateral lower back pain. She does not have any palpable spasm, but she is not tender to deep palpation in the bilateral lumbar spine.
ASSESSMENT AND PLAN: Lumbar strain. We are going to go ahead and encourage her to take some ibuprofen 600 mg t.i.d. fairly regularly for the next week or so. In addition, we did give her some instructions on some gentle back stretching exercises that she can do.
We encouraged her to do these after she takes her shower, after she has used some heat, when she is most likely to have this spasm minimized. She is having some difficulty getting comfortable and sleeping at night. We are going to try her on Robaxin 750 mg in the evening. She can certainly take it during the daytime as well, if this does not cause any sleepiness or side effects, and for more severe pain, we are going to prescribe her Tylenol No. 3. The patient can take 1 to 2 in the evening as needed.
If the patient is not improving within the next 7-10 days, we did tell her we should probably get an x-ray and consider physical therapy. The patient is in agreement with the care plan and she left stable.
