Musculoskeletal SOAP Note

Patient: C.T. 38 y/o BM

DOB: 03/15/1975

Visit: 04/21/2015, 1000

Chief Complaint: “I am here because my back hurts.”

HPI: C.T. a 38 y/o BM presents to the clinic for an evaluation of low back pain. He describes the pain an aching (Character) sensation that is located in the lower back region (Location) and is an 8 on a scale of 1-10. Denies the pain radiating into lower legs (Radiating). The pain started approximately 1 day ago (Onset) after moving heavy boxes at work (Timing) and the pain has never went away (Duration). He states that when he lifts heavy boxes at work, his lower back starts to hurt (Aggravating Factors). He states that he has put a warm compress to his lower pack to help with the pain and has takes Ibuprofen every 6 hrs for his back pain (Alleviating Symptoms). He denies any associating symptoms with his back pain (Associating Symptoms). He also has a burning feeling on top of both feet (Location). States that the dull numbness “feels like electrical burning” (Character) and the burning starts every evening (Timing) and gets worse at night several hours before he goes to bed (Duration) and does not radiate to any other parts of the body (Radiation). States that the burning feeling in feet started a year ago when he was diagnosed with Type II Diabetes (Onset) and hurts worse when he walks a lot (Aggravating Factors) but feels better when he soaks his feet in warm water (Alleviating Factors).

Medical HX: Pt was diagnosed with high cholesterol and type 2 diabetes 1 year ago. Both are well controlled with medication, diet, and exercise. No other childhood or adult diseases, and immunizations UTD. He received the flu vaccine 10/2013. No psychiatric history.

Surgical HX: No surgical history.

Medications: Ibuprofen 400 mg by mouth every 6 hours as needed for back pain (last taken

6 hours ago)

Lipitor 20 mg by mouth daily (last taken this morning)

Amaryl 2 mg by mouth every morning (last taken this morning)

Allergies: NKA

Personal/social HX: Married, has 2 children, works at Home Depot as a General Manager. He walks 30 minutes 3x a week.

Drugs, Alcohol, or Smoking HX: No illegal drug use, no alcohol or tobacco use.

Family HX: Mother-gallbladder removed at age 60, Type II DM. Father- Died from MI

at age 80. No siblings.

Review of Systems

General: Reports being “as healthy as can be” (-) fever (-) chills (-) recent weight gain or loss (-) weakness (-) fatigue. States her last physical exam was in 2014.

Skin, hair, & nails: (-) changes in skin (-) changes in hair (-) changes in nails.

HEENT: head – (-) injury (-) headaches (-) hair loss. eyes – (-) decreased vision (-) watery eyes (-) photosensitivity. last eye exam 1/2015. ears – (-) hearing problems (-) tinnitus (-) ear pain (-) drainage. nose – (-) nasal congestion (-) allergies (-) nasal drainage (-) epistasis

throat – (-) sore throat (-) tooth ache (-) pain or difficulty with swallowing. last dental exam 2 years ago.

Thorax/lungs: (-) chest pain (-) lung injury (-) lung disease (-) allergies (-) asthma.

Cardiovascular: (-) chest pain (-) irregular heartbeat (-) palpitations (-) murmurs (-) hypertension.
PVS: (-) extremity edema (-) coldness (-) leg cramps (-) ulcers.

Abdomen: Regular diet. (-) nausea (-) vomiting (-) bowel problems (-) abdominal pain (-) bloating (-) excess gas (-) diarrhea. Last bowel movement was yesterday. Mother had gallbladder removed, see FMH.

GU: (-) urinary frequency (-) hesitancy (-) incontinence (-) nocturia (-) flank pain (-) burning (-) bleeding with urination.

Metabolic/Hematologic: (+) type I or II DM (-) thyroid problems (-) heat/cold intolerance (-) bruising (-) ease of bleeding. No history of blood transfusions.

Musculoskeletal: (-) trauma (+) injury to lower back.

Psychiatric: (-) trouble concentrating (-) nervousness (-) anxiety (-) panic attacks (-) mood changes (-) hearing voices (-) frequent unhappiness (-) desire to harm self/others (-) sleep trouble (-) nightmares (-) memory loss (-) excessive life stresses. No recent deaths in family or close friends.

Neurologic: (-) history of stroke (-) seizures (-) frequent/incapacitating headache (-) tremors in right hand (-) numbness in feet (+) burning in feet


Vital Signs: B/P 120/70, P-80, R-20, T-98.4, BMI 33, Wt 198Lbs, HT 5’9.

General: Friendly, well-groomed, AAOX3, good eye contact and speech, appears relaxed and calm. Reliable historian.

Physical Assessment

Hair: Average texture dark brown, shiny hair. Evenly distributed on scalp with no breakage,

alopecia, dryness or infestations.

Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.

Nails: Smooth and well manicured without clubbing or cyanosis. Capillary refill to finger pad is < 2 sec.

Head/Neck: Normocephalic/atraumatic, no bumps, bruises, lesions. Scalp pink and dry. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline.

Eyes: Pupils 4mm constricting to 2mm, PERRLA, vision 20/20 in each eye, vision fields full by confrontation. negative strabismus and nystagmus, disk margins sharp, without hemorrhages, exudates. No anterior narrowing. Conjunctiva pink; sclera white.

Ears: Acuity good to whispered voice. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 o’clock right, 7 o’clock left).

Nose: Turbinates intact, nares patent, septum midline, No tenderness over maxillary sinuses. mucosa pink with no swelling or drainage noted from both nares. No nasal flaring or discharge.

Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates.

Lungs: Respirations 12 breaths/min, breath sounds vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally.

Heart: No Scratching noise heard at lower left sternal border. Apical pulse 90 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 best at base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to the midsternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps. Pain not elicited with chest wall palpation.

Breasts: Deferred per patient’s request.

Abdomen: Protuberant. Normoactive BS x 4 quadrants. No abdominal pulsations or bruits. No pain upon palpation. No palpable masses or hepatosplenomegaly. Kidneys not felt, no flank pain or CVA tenderness.

Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes nonpalpable.

Extremities: Extremities are warm without edema. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulse are all 2+ and symmetric. Full range of motion to all extremities.

Genitals: Deferred at patient’s request

Rectum/Anus: Deferred at patient’s request

Neurologic: AAOX3, cooperative and calm. Cranial nerves II-XII intact. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric.

Musculoskeletal: Normal gait. Tenderness with range of motion on flexion, extension, lateral bending, right rotation, and left rotation. Normal cervical, thoracic, and lumbar curves. Uptight spinal column with alignment of the shoulders, iliac crests, and skin creases below the buttocks. Full range of motion in all joints with no deformities, radiation, or swelling. Palpable muscle spasm in lumbosacral area. Positive monofilament test to right and left great toe and all metatarsals on feet.


  1. Diagnosis- Mechanical Low Back Pain
  2. Diabetic Peripheral Neuropathy (Distal Symmetric Sensorimotor Polyneuropathy)

I. Diagnosis- Mechanical Low Back Pain

Mechanical back pain is an aching pain is an aching pain located in the lumbosacral area and sometimes will radiate into the lower legs, especially along L5 (lateral leg) dermatones or S1 (posterior leg) dermatones (Bickley, 2013). Lower back pain often arises from muscle and ligament injuries and usually last less than 3 months (acute), idiopathic, benign, and self-limiting. Mechanical back pain is commonly work related and most commonly occurs in patients between the ages of 30-50 y/o (McCance, 2010). Risk factors for mechanical low back pain are: heavy lifting, poor conditioning, and obesity (Bickley, 2013).

Differential diagnosis:

  1. Ankylosing Spondylitis
  2. Diffuse Idiopathic Hyperostosis (DISH)
  3. Herniated disc
  4. Spinal Stenosis
  5. Lumbar Spinal Stenosis
  6. Osteoarthritis
  7. Rheumatoid Arthritis
  8. Sciatica (Redicular Low Back Pain)
  9. Metastatic Malignancy


Provide Pain Relief

Nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen 300 mg QID as needed or gabapentin (Neurontin) 300mg TID. Gabapentin is often used for neuropathic pain symptoms and approved by the FDA for its use (Edmunds & Mayhew, 2014). Cyclobenzaprine (Flexeril) 5-10mg for 2-3 weeks maximum may be used for the treatment of muscle spasms. CT should be instructed that Neurontin and Flexeril cause drowsiness, a common side effect (Edmunds & Mayhew, 2014). Because CT is taking Ibuprofen with minimal relief, a prescription muscle relaxant may be prescribed for a short time to help relieve symptoms.

Ice & Heat Application

Applying ice or heat to the back helps relax muscles and decrease muscle inflammation. Apply heat to the area for 20 minutes and, if the patient prefers, ice can be applied to the area for 20 minuets. Heat/Ice should be applied to the area 2-3 times per day. If the patient finds one application more helpful than the other, than he should use only that application (Cleveland Clinic, 2014).

Short Term Bed rest

Short-term bed rest for 24-48 hours may help alleviate severe back pain and back spasms (Mayo Clinic, 2015). CT may need bed rest for 24 hours to alleviate his back pain and back spasms.

Physical Activity

In mild to moderate pain, patients are encouraged to resume a near-normal schedule. For CT, activity as tolerated with modifications, such as, no lifting objects > 10 lbs x 2 weeks minimum or until his lower back pain and back spasms are gone, which may take longer (Bickley, 2013).

Additional tests if needed

Mechanical low back pain is usually self-limiting and additional testing is not usually necessary. If CT’s symptoms worsen or has signs and symptoms of a possible infection, a CBC, Sed rate, X-Ray, CT scan/MRI and/or nerve conduction studies may be ordered if needed (Bickley, 2013).

Teaching and follow up

Because low back pain is often the result of improper body mechanics, and CT lifts heavy boxes at his job, methods to prevent back injury should be reviewed. The review of correct body mechanics are: maintaining correct posture, proper lifting of heavy objects, and regular practice of back-friendly stretches and exercises (Mayo Clinic, 2014). A follow-up appointment in 2 weeks should be made to reassess CT’s pain and plan of care. Ct must be instructed to report any temp > 101, unrelieved pain, pain radiating down legs, weakness, numbness, tingling in any part of the body, and bowel or bladder problems. These symptoms may indicate a serious medical problem (Mayo Clinic, 2015).

DiagnosisDiabetic Peripheral Neuropathy

Diabetes cause several different types of peripheral neuropathy, the most common is Distal Symmetric Sensorimotor Polyneuropathy. A burning or electrical pain often occurs at night. Vibration sense is often the first sensation to be lost in peripheral neuropathy (Bickley, 2013).

Differential diagnosis:

  1. autonomic Dysfunction
  2. Mononeuritis Multiolex
  3. Diabetic Amyotrophy


Check blood sugar, vitamin B12 & A1C level

To help manage the symptoms of diabetic peripheral neuropathy, it is important to keep blood sugar levels under control. Management of blood sugar levels will improve symptoms of neuropathy (McCance, 2010). The A1C level checks blood sugar over the last 2-3 months to evaluate overall blood sugar control. The A1C goal should be < 6.5 and fasting blood sugar should be < 126mg/dl (Bickley, 2013). It is crucial that CT manage his blood sugar levels to prevent microvascular and macrovascular disease and prevent or delay the onset of complications (Edmunds & Mayhew, 2014). The American Diabetes Association recommends a preprandial blood glucose level between 70-130 mg/dl (McCance, 2010). Vitamin B12 deficiency can cause neuropathy symptoms; therefore, it is appropriate to check a vitamin B12 level (McCance, 2010).

Therapeutic Lifestyle Changes

Diet and lifestyle changes are important in the management of diabetes. CT’s weight and BMI are within normal limits and he exercises regularly. It is important to review his knowledge of diabetic diet, how and when to check blood sugar, signs of hypoglycemia, and foot care. In addition to this, it is important to review proper administration his home medication, Amaryl 2mg daily, because it must be taken with food (Edmunds & Mayhew, 2014). Furthermore, CT should be instructed to avoid herbal products such as bitter melon, fenugreek, and St. John’s Wart because these medications can have variable effects on blood sugar levels (Edmunds & Mayhew, 2014). In addition to this, CT should continue to exercise because it will help reduce his neuropathy pain (Mayo Clinic, 2014).

Check Feet Daily

It is important of CT to check his feet daily for blisters, cuts, or calluses. Diabetics with neuropathy have decreased sensation in their feet and cuts or blisters can become infected and lead to amputations (McCance, 2010). CT should be informed to wear soft, loose cotton socks and padded shoes. A semicircular hoop can be used at nighttime to keep bedcovers off sensitive feet and help reduce neuropathy symptoms (Mayo Clinic, 2014).

Refer to Registered Dietitian and Diabetes Educator

Ct is very compliant with his treatment program for diabetes; however, if he was noncompliant or lacked information, a referral would be made. In patients lacking information, a referral is mandatory for information and self-care (Edmunds & Mayhew, 2014).

Refer to Neurologist

A referral is necessary to rule out any other causes of CT’s neuropathy. The neurologist will be able to perform further testing such as: CT/MRI, nerve function tests, nerve biopsy, skin biopsy and offer alternative treatment options if appropriate for the patient (McCance, 2010).

Follow up care

A follow-up appointment will be made with the patient in 2 weeks to review his

treatment plan, medications and lab results. CT should be instructed to report any

changes in sensation, or worsening of symptoms. The patient should continue to

use Ibuprofen 300 mg QID as needed and gabapentin (Neurontin) 300mg TID for

his neuropathy. The effectiveness of these medications will be evaluated and

treatment changes will be made if beneficial for the patient.


Bickley, L. S., & Szilagyi, P. G. (2013). Bates’ guide to physical examination and history taking (11th ed.).

Cleveland Clinic. (2015). Acute mechanical back pain [Brochure]. Cleveland Clinic: Author.

Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for the primary care provider (4th ed.). St. Louis, MO: Elsevier Mosby.

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The

biologic basis for disease in adults and children (6th ed.).

The Mayo Clinic. (2015). Peripheral neuropathy [Brochure]. Mayo Clinic Health Systems : Author.