Focused SOAP note Scenario #1 Patient Initials: AB______ Age: 42_______ Gender: _M_____ Chief Complaint: Lower back pain History of Present Illness (HPI): A.B. is a 42 year old Caucasian male who presents today with complaints of lower back pain. He states the pain has been on-going for a month and occasionally radiates down his left leg and sometimes feels that his leg is numb. A.B. cannot recall any recent injury but states it is worse after his shifts as a construction worker and has tried ice and heat to relieve the pain but it has not been effective. He has been taking Tylenol and Ibuprofen over the counter for the last week which is previously was effective but over the last week pain has increased. Back pain relieves with rest. Medications: Citalopram-20 mg po daily Over the counter multivitamin Tylenol 1000 mg every 6 hours Ibuprofen 800 mg every 6 hours Allergies: No known allergies (NKDA) Past Medical History (PMH):
Depression Anxiety Past Surgical History (PSH): No past surgical history Personal/Social History: Married, two children ages 10 and 8. Works as a construction worker,
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- Summer '15
- Spinal disc herniation