SOAP Detailed

Subjective

• 54yo M (Thomas Vance, DOB 14/08/1971, MRN 492-810-44) presents at 09:15 on 25/03/2026 for acute lumbar back pain, routine HTN review, and T2DM f/u.
• PMH: Essential HTN (dx 2018), T2DM (dx 2021), hyperlipidaemia. PSH: Laparoscopic appendicectomy (2005).
• Current meds: lisinopril (Prinivil®) 20 mg PO daily, metformin (Glucophage®) 1,000 mg PO BID, atorvastatin (Lipitor®) 20 mg PO daily, ibuprofen (Advil®) 400 mg PO TID PRN, turmeric root extract 500 mg PO daily.
• SHx: Warehouse supervisor (heavy lifting); former smoker (quit 2015, 15 pack-yr hx); EtOH 2-3 beers/wk; lives with spouse.
• Allergies: Penicillin (maculopapular rash); NKFA.

Pt reports acute onset lower back pain starting 3 days ago after lifting a 20 kg crate at work. Pain is localised to the lumbar paraspinal region without radiculopathy. Described as a constant dull ache (5/10) with sharp exacerbations (8/10) upon flexion or twisting. Worsened by prolonged sitting and bending; mildly relieved by lying flat on a firm surface.

He has been taking OTC ibuprofen (Advil®) 400 mg PO TID for the past 3 days with only transient, partial relief of the lumbar pain. He remains fully adherent to lisinopril, metformin, and atorvastatin with good baseline control of HTN and T2DM.

Pt reports mild epigastric dyspepsia since initiating regular ibuprofen use three days ago, but denies any adverse effects from his chronic maintenance medications.

He has applied a heating pad for 20 minutes each evening and attempted gentle hamstring stretches, noting brief, mild muscle relaxation.

His job requires repetitive lifting and twisting, and his baseline physical activity outside of work is largely sedentary with a diet high in processed carbohydrates.

Pt is frustrated by the functional limitation and anxious about missing shifts, attempting to work through the discomfort by relying on OTC analgesics.

Over the past 24 hours, the paraspinal muscle stiffness has become more pronounced upon waking, though he has not developed any lower extremity weakness or sensory deficits.

ROS is positive for localized lumbar myalgia and mild dyspepsia, and negative for saddle anaesthesia, bowel or bladder incontinence, fever, weight loss, or chest pain.

Review of Systems

• General: Denies fever, chills, night sweats, fatigue, or unintentional weight loss.
• Skin: Denies rashes, pruritus, dryness, or lesions.
• Head: Denies headache, dizziness, lightheadedness, or syncope.
• Eyes: Denies blurred vision, diplopia, eye pain, or redness.
• Ears: Denies hearing loss, tinnitus, vertigo, or otalgia.
• Nose: Denies nasal congestion, rhinorrhoea, or epistaxis.
• Throat: Denies sore throat, odynophagia, or hoarseness.
• Neck: Denies neck lumps, pain, or stiffness.
• Respiratory: Denies cough, SOB, wheezing, or haemoptysis.
• Cardiovascular: Denies chest pain, palpitations, orthopnoea, or peripheral oedema.
• Gastrointestinal: Reports mild epigastric dyspepsia; denies nausea, vomiting, diarrhoea, constipation, haematemesis, or melaena.
• Genitourinary: Denies dysuria, urinary frequency, urgency, haematuria, or incontinence.
• Musculoskeletal: Reports lumbar back pain and paraspinal stiffness; denies peripheral joint swelling or arthralgias.
• Neurological: Denies lower extremity numbness, paraesthesias, focal weakness, or saddle anaesthesia.
• Psychiatric: Reports mild situational anxiety regarding work; denies depression or sleep disturbances.
• Endocrine: Denies heat or cold intolerance, polydipsia, or polyuria.
• Hematologic/Lymphatic: Denies easy bruising, prolonged bleeding, or lymphadenopathy.
• Allergic/Immunologic: Denies seasonal allergies or recurrent infections.

Objective

• Vital Signs:
  • Blood Pressure: 146/88 mmHg
  • Heart Rate: 78 bpm
  • Respiratory Rate: 16 breaths/min
  • Temperature: 36.8 °C
  • Oxygen Saturation: 98 % on RA
• General Appearance: Alert, oriented x3, NAD, ambulating with a mildly antalgic gait and guarded lumbar posture.
• HEENT: NCAT, PERRLA, EOMI, TMs normal bilaterally, oropharynx clear with moist mucous membranes.
• Neck: Supple, full ROM, trachea midline, no thyromegaly or lymphadenopathy.
• Cardiovascular: RRR, normal S1/S2, no murmurs, rubs, or gallops; peripheral pulses 2+ throughout.
• Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
• Abdomen: Soft, non-distended, mild epigastric tenderness without rebound or guarding, normoactive bowel sounds.
• Musculoskeletal: Bilateral lumbar paraspinal muscle tenderness and spasm (L3-L5); no midline spinous process tenderness; flexion limited to 45 degrees by pain; negative straight leg raise bilaterally.
• Neurological: CN II-XII intact; lower extremity motor strength 5/5 bilaterally (L2-S1); sensation intact to light touch throughout; patellar and Achilles reflexes 2+ and symmetric.
• Skin: Warm, dry, intact without erythema or lesions over the lumbar spine; diabetic foot exam reveals intact skin and normal monofilament sensation bilaterally.

Assessment

• Acute mechanical lumbar strain with secondary pain-induced BP elevation, on a background of stable T2DM and essential HTN.

Acute low back pain

Assessment

• Lumbar sprain and strain
• Lumbar disc herniation, degenerative disc disease, vertebral compression fracture

Diagnostic Tests:

• None indicated at this time given absence of neurological red flags and symptom duration < 4 weeks.

Treatment Plan

• Discontinue ibuprofen due to dyspepsia; start paracetamol (acetaminophen, Tylenol®) 1,000 mg PO TID PRN pain and cyclobenzaprine (Flexeril®) 5 mg PO QHS PRN muscle spasm for 5 days; continue superficial heat and light activity as tolerated; provide work note restricting lifting > 5 kg for 7 days.
• Refer to outpatient physical therapy for lumbar stabilisation and core strengthening if not significantly improved in 2 weeks.

Elevated blood pressure

Assessment

• Essential hypertension
• Secondary hypertension due to acute pain and recent NSAID use

Diagnostic Tests:

• BMP to evaluate renal function and electrolytes following recent NSAID use; home BP monitoring log.

Treatment Plan

• Continue lisinopril (Prinivil®) 20 mg PO daily; hold dose escalation today as mild BP elevation is likely secondary to acute pain and NSAID use; monitor BP at home BID.
• None - Essential hypertension

Type 2 diabetes mellitus

Assessment

• Type 2 diabetes mellitus without complications
• Medication non-adherence, dietary indiscretion

Diagnostic Tests:

• Point-of-care HbA1c, fasting lipid panel, and urine albumin-to-creatinine ratio.

Treatment Plan

• Continue metformin (Glucophage®) 1,000 mg PO BID and atorvastatin (Lipitor®) 20 mg PO daily; reinforce low-glycaemic diet and daily foot inspections.
• Annual referral to optometry for dilated diabetic retinal examination. - Type 2 diabetes mellitus without complications

Follow-Up

• Seek immediate ED evaluation if experiencing bowel or bladder incontinence, urinary retention, saddle anaesthesia, or progressive lower extremity weakness. Return to clinic in 4 weeks to review home BP log and diabetic lab results, or sooner if needed.
• Schedule an earlier follow-up in 1-2 weeks if lumbar pain persists without improvement, worsens, or begins radiating down the legs.
• Pt counselled on proper lifting mechanics, medication side effects (specifically sedation with cyclobenzaprine), and NSAID avoidance; he verbalised clear understanding and agreement with the treatment plan.