Soap Note Template (Medical Knowledge) printable pdf download

Patient Name ________________ Examinee Label_______________________

SOAP NOTE

Do Not write on opposite side of page

Comments

Case __________ Examinee Name________________

Date________

S cc: 35 yo Caucasian male presents with low back pain x 2 days.

Hxcc: Patient was shoveling snow when pain started in the low back on the right side. Pain started at

SOAP NOTE

an 8/10 and now is a 6/10 pain described as tight and constant. Activity makes pain worse, nothing

makes it better. Patient has taken Motrin and used a heating pad since onset. Patient denies any

numbness, tingling, burning pain, or pain that radiates down either leg, also denies any previous low

back trauma or pain.

HTN – Controlled with Metoprolol.

PMH:

PSH:

None

Meds:

Metoprolol for HTN.

Allergies: NKDA

FH:

Mother arrhythmia and CAD, Father CAD.

SH:

Smoked 15 years ago, unknown pack years. 3 glasses of wine/week.

Bank Teller.

ROS:

General: Denies change in weight, fatigue, insomnia

CV: Denies chest pain, irregular heartbeat, rapid heart beat

Score__/_

Resp: Denies shortness of breath, dyspnea on exertion, cough, orthopnea

GI: Denies nausea, vomiting, constipation, diarrhea, heartburn

Musculoskeletal: denies recent fractures, sprains, strains, limited use of any joint

Neurological: Denies seizures, tremors, numbness or tingling

VS: T 98.5º F, BP 129/80, R 14, P 72

Gen:

Minimal distress. Alert and oriented to person, place, and time.

Pleasant Affect.

Heart:

RRR, no murmurs, gallops, or rubs.

Lungs:

CTA in all 6 lung fields.

Neuro: Lower Extremity Strength 5/5 and symmetric. Lower extremity reflexes +2/4, symmetric at

patella and Achilles.

Musculoskeletal: Gait with hip hike on left heel strike. Moderate tenderness at right L5 and sacroiliac

Score__/__

junction. Negative straight leg test. R upper lumbar hypertonicity. Decreased ROM to trunk flexion.

+ R standing flexion test, – seated flexion test. L5FRSright. R anterior innominate.

(Diagnosis and/or problem list)

1. Low back strain

1. Ibuprofen, PRN

2. Somatic Dysfunction

2. OMT utilizing Muscle Energy to

- Lumbar, Pelvis

Pelvis - Pt tolerated Tx well with

3. HTN – Controlled with Meds

decreased pain and improved

structural findings

3. F/U in 2 days and call if worsening

symptoms

Score__/__

Soap Note Template (Medical Knowledge)

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