Episodic Focused SOAP Note on Back Pain Discussion

Patient Information:

A 42-year-old male.

S.

CC (chief complaint): Lower back pain

HPI: The patient is a 42-year-old male who reports lower back pains for the past month. He reports that the pain occasionally radiates to his left leg.

I would like to know if the onset of the pain was sudden or gradual. I would like to know the character of the pain. Is it sharp, aching, or burning? Is it continuous or intermittent?

I would also like to know if there are any associated symptoms. These symptoms include fecal or urinary incontinence, weakness and numbness of the limbs, weight loss, fever, night sweats etc.

I would like to know if there are any exacerbating or relieving factors to this pain. Is it worse when walking, sitting, or lying flat? Is the pain worsened by coughing or straining? What does he do to relieve the symptoms? Has he taken any medications to try and relieve the symptoms?

I would like to know if the pain is getting better or worse. I would also like to know the severity of the pain by asking the patient to grade the severity on a scale of 1-10

I would ask the patient if he has ever experienced back pain in the past and if it is similar to what he’s experiencing now.

I would ask if the patient has any previous trauma or injuries that might have preceded his symptoms.

Current Medications: I would ask for any medications the patient is taking e.g. steroids or analgesics.

PMHx: I would check if the patient has any musculoskeletal condition such as osteoarthritis.

I would ask the patient if he has had spinal surgery before.

Soc Hx: I would ask about the patient’s occupation. Does it involve carrying around heavy loads?

Does the patient take alcohol or tobacco?

Travel Hx: I would ask about any recent visits to TB endemic areas or areas with a high prevalence of TB. This is important as TB can cause Pott’s disease (Wong et al., 2017).

Fam Hx:  I would ask if anyone in his family has had similar symptoms before.

ROS:

GENERAL:  I will ask for constitutional symptoms such as weight loss, fatigue, fevers, night sweats and chills.

GENITOURINARY:  I will ask for urinary incontinence or retention.

NEUROLOGICAL:  I will ask for weakness, numbness, paralysis, or tingling in the extremities. I will ask in changes in bowel or bladder control

MUSCULOSKELETAL:  I will ask for muscle pain, joint stiffness.

HEMATOLOGIC:  I will ask for signs of anemia, bleeding or bruising.

LYMPHATICS: I will ask for the presence of enlarged lymph nodes.

O.

Physical exam: I will check the vital signs i.e., the temperature, BP, respiratory rate and pulse rate.

MUSCULOSKELETAL:

Inspection:  Check for the spinal alignment. Check for muscle wasting. Check for bruising which might suggest recent trauma or surgery. Gait and Posture test to observe the overall posture and how the patient walks. Range of motion. To test for extension of the spine, forward flexion, lateral flexion and lateral rotation of the spine.

Palpation and percussion of the spine. Done to assess the alignment of the spine and note any tenderness and muscle spasms. Palpation of the sciatic notch. Tenderness over this area with radiation of pain to the leg may indicate an irritation of the sciatic nerve.

NEUROLOGICAL (of the lower limb).

Inspection: Check for muscle wasting, fasciculations, and tremors

Palpation: this includes assessing the tone and power of the muscle groups

Reflexes. Testing the ankle and knee reflexes can help with determining the level of spinal cord compromise.

Motor testing and sensory testing to assess for muscle weakness and sensation. The nerve roots that are most likely affected are L4, L5, and S1.

L5: The sensory component is tested on the dorsum and medial aspect of the big toe. The motor component is tested by asking the patient to dorsiflex the great toes (Stecco et al., 2019)

L4: The sensory component is tested on the medial aspect of the lower leg and ankle. Dorsiflexion of the great toe can be used to check for some L4 root dysfunction of the motor component.

S1: The sensory component is tested on the dorsum and lateral aspect of the little toe. The motor component is assessed by asking the patient to flex their knee so that the foot lies flat on the bed. This test assesses the hamstrings. Testing for these nerves can help to detect nerve root dysfunction.

Diagnostic tests:

  1. A complete blood count (CBC) is necessary. By studying the blood parameters, we can rule out an infection or a malignancy. A raised white cell count can suggest an infection. Iron deficiency anemia can be a sign of malignancy.
  2. Erythrocyte sedimentation rate should be tested. A raised ESR can point towards ankylosing spondylitis (Ranganathan et al., 2017).
  3. Liver function tests. An elevated ALP may be a sign of bony
  4. Bone profile. Hypercalcemia may be a sign of malignancy.
  5. Plain X-rays of the spine. Done to screen for possible fractures or other bony deformities.

 

A.

Differential Diagnoses

  1. Nerve tumors such as neurofibroma of the cauda equina. This can present with sciatica. The pain is usually continuous (Solomon & Wakeley, 2017).
  2. Intervertebral disc prolapse. This is caused by physical stress. Herniation of the nucleus can cause compression of the cauda equina which may present with pain in the lower limb (Solomon & Wakeley, 2017).
  3. TB of the spine. This can also lead to degeneration of the spinal and compression of the surrounding structures. Pain is a common presentation (Solomon & Wakeley, 2017).
  4. Vertebral fracture. Pain is a common symptom of fractures. Fractures can also lead to compression of the nerve roots which may present with pain and weakness of the lower limbs (Solomon & Wakeley, 2017).
  5. Muscular strain and spasms. These can result in pain in the lower back and difficulty in forward flexion (Solomon & Wakeley, 2017).

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

  • Ranganathan, V., Gracey, E., Brown, M. A., Inman, R. D., & Haroon, N. (2017). Pathogenesis of ankylosing spondylitis—recent advances and future directions. Nature Reviews Rheumatology, 13(6), 359-367. https://doi.org/10.1038/nrrheum.2017.56
  • Solomon, L., & Wakeley, C. (2017). Diagnosis in orthopaedics. In Apley and Solomon’s System of Orthopaedics and Trauma (pp. 450-500). CRC Press.
  • Stecco, C., Pirri, C., Fede, C., Fan, C., Giordani, F., Stecco, L., & De Caro, R. (2019). Dermatome and fasciatome. Clinical Anatomy, 32(7), 896-902. https://doi.org/10.1002/ca.23408
  • Wong, Y. W., Samartzis, D., Cheung, K. M. C., & Luk, K. (2017). Tuberculosis of the spine with severe angular kyphosis: mean 34-year post-operative follow-up shows that prevention is better than salvage. The Bone & Joint Journal, 99(10), 1381-1388. https://doi.org/10.1302/0301-620x.99b10.bjj-2017-0148.r1