General Practice SOAP Note

S

• Presents with acute low back pain, requesting a work note. Also reports worsening generalized anxiety and requests a routine BP check and refill.

• Back pain: x 3 days, acute onset after lifting heavy boxes at work. Localized to the lower lumbar region, dull ache with sharp spasms on movement, severity 7/10. Anxiety: persistent over the past 2 months, worse in the mornings and on Sunday evenings before the workweek.

• Back pain aggravated by bending, twisting, and prolonged sitting; mildly relieved by lying flat and ibuprofen (Advil®) 400 mg PO TID. Anxiety aggravated by work deadlines; deep breathing exercises provide minimal relief.

• Progression: Back pain peaked on day 2, slightly improved today. Anxiety has gradually increased over the last 8 weeks.

• Previous episodes: Similar lumbar strain 2 years ago, resolved after 1 week of conservative management and physiotherapy. History of mild situational anxiety in university, managed with counselling.

• Impact on daily activities: Unable to perform heavy lifting duties as a warehouse supervisor. Poor sleep initiation due to racing thoughts, causing daytime fatigue.

• Associated symptoms: Denies saddle anesthesia, bowel/bladder incontinence, lower extremity weakness, or radicular pain. Denies panic attacks, chest pain, palpitations, or suicidal ideation.

• Issues raised: 1. Acute low back pain; 2. Generalized anxiety; 3. Hypertension follow-up and medication refill.

PMedHx

• Essential hypertension (diagnosed 2021). Current meds: amlodipine (Norvasc®) 5 mg PO daily. No prior spinal surgeries or imaging. NKDA.

• Occupational exposure to repetitive heavy lifting. No recent travel or sick contacts.

• Immunizations up to date, including tetanus (Tdap 2020), annual influenza, and COVID-19 boosters.

• Other: Adherent to antihypertensive therapy with no reported side effects.

SocHx

• Works full-time as a warehouse supervisor; high physical and mental demands, currently short-staffed. Lives with spouse, supportive relationship. Non-smoker, EtOH 2–3 drinks/week, denies recreational drug use.

FHx

• Father: HTN, T2DM. Mother: GAD, osteoarthritis.

O

• NAD BP: 134/82 mmHg, HR: 78 bpm, Wt: 84 kg, T: 36.8 °C, O2: 99 %, Ht: 178 cm

• CVS: N S1 and S2, no murmurs or extra beats. Resp: Chest clear, no decr breath sounds. Abdo: No distension, BS+, soft, non-tender to palpation and percussion. No organomegaly. Back: Normal gait. Tenderness to palpation over bilateral lumbar paraspinal muscles (L4–S1), no midline spinous process tenderness. ROM limited in flexion (60 degrees) due to pain. Straight leg raise negative bilaterally. Lower extremity neuro intact (power 5/5, reflexes 2+, sensation intact L2–S1). Psychiatry:

  • Appears well, approp dressed for occasion.
  • Normal speech
  • Reactive affect
  • No perceptual abnormalities
  • Normal thought form and content
  • Intact insight and judgement
  • Cognition grossly normal

• GAD-7 score today: 12/21 (moderate anxiety). Home BP log review (past 14 days): average 128/78 mmHg.

A/P

• 1. Acute low back pain

• Lumbar sprain/strain

• Lumbar disc herniation, facet joint osteoarthritis, spondylolisthesis

• None indicated at this time (no red flags)

• Continue ibuprofen (Advil®) 400 mg PO TID PRN with food for 5 days, add cyclobenzaprine (Flexeril®) 5 mg PO QHS PRN for 5 days. Apply heat/ice. Remain active as tolerated. Provided work note for modified duties (no lifting > 5 kg) for 1 week.

• Physiotherapy

• 2. Generalized anxiety

• Generalized anxiety disorder

• Adjustment disorder with anxious mood, hyperthyroidism, major depressive disorder

• TSH, CBC, ferritin

• Discussed sleep hygiene and mindfulness resources (MindShift CBT app). Escitalopram (Cipralex®) 10 mg PO daily (take 5 mg PO daily for 1 week, then increase). Follow up in 4 weeks to assess response and tolerability.

• Cognitive behavioural therapy (CBT) via local community mental health program

• 3. Hypertension follow-up

• Essential hypertension

• White coat hypertension, secondary hypertension

• Annual screening labs: fasting lipid profile, HbA1c, electrolytes, creatinine, eGFR, ACR

• Continue amlodipine (Norvasc®) 5 mg PO daily (dispense 90 days with 3 refills). Encourage continued low-sodium diet and regular aerobic exercise once back pain resolves.

• None