Episodic/Focused SOAP Note:Back Pain

  • Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
  • Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 
  • Review the following case study:

 

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Answer

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials: F.A.

 Age: 42 

Sex: Male 

Race: African American

S.

CC (chief complaint): Lower back pain for one month. 

HPI: The patient is a 42-year-old African American male who has presented to the clinic with complaints of lower back pain that has lasted for one month. He reports that the pain radiates to his left leg sometimes. 

Location: Lower back.

Onset: Last month. 

Character: Sharp, persistent, radiating to the left leg sometimes. 

Associated signs and symptoms: None reported. 

Timing: In strenuous physical activity. 

Exacerbating/ relieving factors: Any physical activity and movement. Pain is relived by analgesic medication, ibuprofen. 

Severity: 8/10 on a pain scale of 0-10.

Current Medications: PO ibuprofen 200mg 3 tabs 6hrly PRN for his lower back pain. PO amlodipine 10mg BD for hypertension. 

Allergies: No known food or drug allergies. No reported seasonal, perennial, or allergy to latex.

PMHx: Hypertension was diagnosed one year ago. He obtained his influenza vaccine in 2021, Tdap vaccine in 2019, and pneumococcal vaccine in 2020. He received all his childhood immunizations up to date. 

 Soc Hx: F.A. is married to one wife and has two children. He holds a bachelor’s degree in medical microbiology and works as a lecturer in a medical school. He has no history of smoking but admits to taking 2-3 bottles of beer while with friends during weekends. He has never used any illicit drugs and denies suicidal attempts. He regularly attends the gym and does morning runs daily to maintain his fitness. His hobbies are dancing and going on vacations. He reports supporting his family financially; his favorite diet is traditional African food. His safety measures include smoke detectors installed in his home, using seatbelts when driving, not using his phone world driving, and CCTV cameras in his house. He sleeps around 8 hours every night. He relates well with his family, wife, and children. 

Fam Hx: His father, aged 72, has prostate cancer while his mother, aged 69, has hypertension and type 2 diabetes, well controlled. His maternal and paternal grandparents are dead; his maternal grandmother died of a stroke at 78 and was diabetic, while his maternal grandfather died at 80 due to prostate cancer. His paternal grandmother died of old age at 76 and had chronic obstructive pulmonary disease (COPD), while his paternal grandfather died at 84 due to status asthmaticus. He has an elder brother, aged 58, with diabetes mellitus. His two children, a son, aged 20, and a daughter, aged 16, are all healthy with no issues.  

ROS

GENERAL: No weight changes, fever, chills, or rigors. 

HEENT: No vision loss, hearing loss, epistaxis, sore throat, difficulty swallowing, or hoarseness of voice. 

SKIN: Denies itchiness. 

CARDIOVASCULAR: No chest pain or palpitations. 

RESPIRATORY: No cough, wheeze, or hemoptysis. 

GASTROINTESTINAL: No diarrhea, constipation, nausea, or vomiting. No bowel incontinence 

GENITOURINARY: No frequency, urgency, or hesitancy. No bladder incontinence.  

NEUROLOGICAL: No syncope   

MUSCULOSKELETAL: Lower back pain radiating to the left leg. No joint stiffness. Reports of paresthesia involving the left leg. 

HEMATOLOGIC: No anemia or bleeding tendencies. 

LYMPHATICS: No enlarged lymph node groups.

PSYCHIATRIC: No depression or anxiety. 

ENDOCRINOLOGIC: Denies polyuria, polydipsia, polyphagia, and heat/cold intolerance. 

ALLERGIES: No hives. 

O.

Physical exam:

Vital Signs: Blood pressure 111/79mmHg, Heart rate 78, respiratory rate 16, temperature 37.1°c, oxygen saturation 98% on room air, weight 160 pounds, height 5’9, body mass index (BMI): 26

GENERAL: Oriented to time, place, and person. 

SKIN: No skin eruptions or discoloration.

HEENT: Normocephalic head, atraumatic, pupils equal and reactive to light, normal ear and nose anatomy, no tonsillar enlargement, no lymph nodes palpated within the neck. 

RESPIRATORY: Symmetrical chest movement on inspection, on palpation, trachea is centrally placed, equal chest expansion, bilateral air entry on auscultation. No wheeze or crackles auscultated. 

CARDIOVASCULAR/Peripheral vascular: Normoactive precordium, S1S2 hear sounds auscultated. No additional sounds. All pulses are adequate and present bilaterally, capillary refill of 2 seconds and no edema. 

ABDOMINAL: Normal fullness, no mass palpated, bowel sounds auscultated. 

NEUROLOGICAL: Alert, GCS at 15/15, cranial nerves are all intact. 

MUSCULOSKELETAL: Low back pain with involvement of the left lower limb. No visible traumatic lesion on the involved site. Straight leg and femoral stretch tests on both lower limbs are positive for the left leg. There is increased pain intensity with twisting, extension, and flexion upon performing the tests mentioned above. Schober’s test conducted is positive. 

Diagnostic Tests:

A complete blood count (CBC) may indicate infection if there is leukocytosis.

Inflammatory markers: erythrocyte sedimentation rate (ESR) and C-reactive protein may be elevated. 

Plain radiograph (Lumbar spine X-ray)

Magnetic resonance imaging (MRI) at the lumbosacral region

Computerized tomography (C.T.) scan of the lumbar region

Bone scan at the lumber region.  

A.

Differential Diagnoses 

Lumbar Disc Herniation (LDH) (Primary Diagnosis)

LDH is a common global presentation, with at least 80% reporting an episode (Al Qaraghli & De Jesus, 2020). LDH causes back pain and manifests majorly in the 3rd to 5th decades of life. The male gender is at high risk of getting LDH. Most cases of LDH involve the root values L4-5 and L5-S1. Risk factors predisposing to LDH include family history, being male, stressful occupation, heavy weightlifting, smoking, and low socioeconomic status. The pathophysiology of LDH involves reduced water retention in the nucleus pulposus, high type 1 collagen ratio in the nucleus pulposus and inner annular fibrosis, apoptosis, collagen, and extracellular matrix destruction, and other inflammatory processes (Al Qaraghli & De Jesus, 2020). Posterolateral disc protrusion causes effects on the traversing root, e.g., L4-5 disc protrusion causes L5 nerve root. Far lateral disc protrusion affects the exiting nerve root, e.g., L5-S1 affects the L5 nerve root. LDH causes patients to experience back pain, sciatica, muscle weaknesses, loss of reflexes, paresthesia, and reduced leg straight rise (Al Qaraghli & De Jesus, 2020). The gold standard imaging modality for diagnosing LDH is MRI. This diagnosis is appropriate for the patient since he has had back pain for one month now with the involvement of the left lower limb. 

Cauda Equina Syndrome (CES)

The cauda equina is a composition of nerves and nerve roots that stem from the distal spinal cord. The typical levels involved are L1-L5, and they comprise axons of nerves innervating the legs, bladder, anus, and perineum (Rider & Marra, 2020). Cauda equina syndrome is caused by compression and disruption of the functioning of the nerves stated above. Rider & Marra (2020) state that CES can be inclusive of conus medullaris or below it and mostly happens when damage involves L3-L5 nerve roots. Patients present with back pain, sciatica, weakness, altered sensation of the lower limbs, bladder/bowel dysfunction, sexual dysfunction, and decreased perineum sensation (Rider & Marra, 2020). Diagnosis is by MRI with sagittal and axial T1 and T2 sequences. CES is a possible differential for the patient because of his back pain involving the left lower limb. 

Lumbar Spinal Stenosis 

Lumbar spinal stenosis is a frequent cause of leg and back pain (Wu & Cruz, 2020). It refers to the narrowing in the vertebra involving the central canal, lateral recess, and neural foramina. The signs and symptoms associated with lumbar spinal stenosis are due to nerve root compression and ischemia. Compression of the nerve roots can be caused by direct mechanical compression or an increase in intrathecal pressure due to the narrowing of the canal (Wu & Cruz, 2020). Clinical manifestations include low back pain, numbness, and tingling. They are mostly bilateral. Diagnosis is with non-contrast lumbosacral MRI (Wu & Cruz, 2020). The patient has a low back, typically with lumbar spinal stenosis. 

Ankylosing Spondylitis (AS)

Wenker & Quint (2023) define AS as a chronic inflammatory disorder of the axial spine. It presents with progressive chronic back pain and stiffening of the spine. The cause is idiopathic. AS mainly affects patients below the age of 40. The pattern of the pain is that it is insidious in onset and only improves upon exercise but not rest. Features associated with AS include buttock, hip pain, postural abnormalities, dactylitis, peripheral arthritis, and impaired spinal mobility. Inflammatory markers, ESR and CRP, are typically raised and diagnostic. The history of back pain validates the appropriateness of AS as a differential for the patient. 

Sciatica 

It is a debilitating condition that causes pain and paresthesia within the regions the sciatic nerve supplies (Davis & Arvind Vasudevan, 2019). Sciatica specifically refers to pain associated with the sciatic nerve or nerve root pathology. The nerve roots that make up the nerve root are from L4 through S2 (Davis & Arvind Vasudevan, 2019). Patients present with invariable unilateral lumbar spine pain. The pain is radicular to the ipsilateral affected extremity. A burning sensation and paresthesia are associated with the pain (Chou et al., 2016). The affected legs may feel heavy. The diagnosis is clinical, and appropriate patient history and physical examination should be conducted. This presentation is typical of the patient’s presentation. He has back pain and left lower limb involvement. 

References

Al Qaraghli, M. I., & De Jesus, O. (2020). Lumbar Disc Herniation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560878/

Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., Fu, R., Dana, T., Kraegel, P., Griffin, J., Grusing, S., & Brodt, E. (2016). Noninvasive Treatments for Low Back Pain. In PubMed. Agency for Healthcare Research and Quality (US). https://pubmed.ncbi.nlm.nih.gov/26985522/#:~:text=For%20acute%20low%20back%20pain%2C%20evidence%20suggested%20that

Davis, D., & Arvind Vasudevan. (2019, November 15). Sciatica. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507908/

Rider, I. S., & Marra, E. M. (2020). Cauda Equina And Conus Medullaris Syndromes. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537200/

Wenker, K. J., & Quint, J. M. (2023). Ankylosing Spondylitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470173/#:~:text=Ankylosing%20Spondylitis%20-%20StatPearls%20-%20NCBI%20Bookshelf.%20Ankylosing

Wu, L., & Cruz, R. (2020). Lumbar Spinal Stenosis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK531493/

 

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