Soap Note June 5th 2025 Siranush Gharibyan.pdf

Soap Note assignment
I Human

1. Siranush Gharibyan, PA-S
Date:06/05/2025
SUBJECTIVE
IDENTIFICATION:
Name: Jack Klein
Date of Birth: 06/19/1976
Age: 50 yo
Gender: Male
Marital Status: Married
Occupation: Accountant

INFORMANT/SOURCE: Pt is a good historian.
Chief complaint: “I have really back pain that started yesterday after I helped my daughter move
into college”
Jack Klein is a 50-year-old male with a history of well-controlled hypertension who presents
with acute onset of low back pain that began yesterday. The pain started while he was lifting
heavy boxes during the process of moving his daughter into her college dorm. The patient
describes the pain as a deep, aching sensation that progressively worsened to a sharp pain with
sudden movement. The pain is localized to the lower back and radiates bilaterally to the buttocks
and down the middle of the posterior thighs.
The pain is constant and severe in intensity, rated 9/10, with 10 being the most painful. The
patient describes it as “the worst back pain I’ve ever had,” which has significantly limited his
ability to walk and stand for extended periods. The pain initially began as general stiffness and
gradually progressed into severe, constant pain that now makes it difficult for the patient to sleep,
put on his shoes, or find a comfortable standing position. Aggravating factors include prolonged
standing, walking, and flexion of the lumbar spine, while lying down provides temporary relief.
The patient denies any history of similar back pain in the past. He has not sought prior medical
attention for this condition. The patient denies other associated neurological symptoms such as
numbness, tingling, muscle weakness, or bowel/bladder incontinence, as well as joint pain,
muscle atrophy, or seizures.
PAST MEDICAL HISTORY:
Adult illnesses (including current): Hypertension diagnosed 10 years ago and is well managed
with Metoprolol 100mg QD and baby aspirin qd.

2. Childhood illness: Denies
Surgical Hx: Denies
Hospitalizations: Denies
Accidents and Injuries: Denies
Ob/Gyn- Pt is male/ not applicable
Psychiatric Hx: Denies
Allergies: Denies Food, Drug, Environmental allergies.
Medications: Prescribe medication: Metoprolol 100 mg qd for HTN management
OTC:Baby Aspirin QD; Herbal: None
Health Maintenance: Last Annual exam was a year ago and colonoscopy screening was also done
a year ago with normal results (requested the results from the GI provider)
Immunizations: Up to date with FLU, Covid, Hep B, all the vaccinations are current.

FAMILY MEDICAL HISTORY:
Grandparents Maternal: No information given
Grandparents Paternal: No information given
Mother: 80 yo with Diabetes Mellitus, HTN, and knee arthritis
Father: Passed away at the age of 50 from Acute MI, had heart disease
Brother aged 55 yo, takes medication for Diabetes Mellitus and HTN.
Daughter 1: 25yo healthy
Daughter 2: 21yo healthy
Familial Disease: Not given
Communicable Diseases: Denies

SOCIAL HISTORY:
Living Situation/family relationships: Lives with wife and 2 daughters
When/if they see other providers: Physical Exam once a year, Colonoscopy is up do date, Dental
visit not asked.

3. Education: Not provided
Barriers to Care/Economic Status: Denies barriers to care, has good insurance
Cultural/Spiritual Practices: Denies
Diet: Regular diet, eats three meals a day
Exercise: Denies regular exercise
Alcohol use: Occasional ingestion of wine on special occasions or when dines out
Smoking/Vape use: Denies smoking/vape use
Drug use: Denies illicit drug use
Caffeine: Couple of cups of coffee daily
Safety Measures: Wears his seatbelt and wears sunscreen daily
Sexual History: Sexually active with his wife (only one sexual partner)

REVIEW OF SYSTEMS:
Gen Survey: Denies recent weight changes, fever or chills
Skin: Denies changing moles, rashes, pruritic symptoms.
Respiratory: Denies shortness of breath, difficulty breathing, coughing up sputum, wheezing.
CV: Denies chest pain, heart palpitations, tachycardia.
GI: Denies abdominal pain, difficulty defecating, abdominal bloating, and blood in stool.
PVS: Denies varicose veins, spasms in the calf, and lower extremity edema.
GU: Denies urinary incontinence, nighttime frequent urination, urinary leaking.
MSK: Denies joint pain, fractures, muscle weakness, muscle atrophy.
Nervous System: Denies upper and lower extremities numbness, tingling, and also denies
seizures.

OBJECTIVE
PHYSICAL EXAM:
Vital Signs: Height: 5’10”. Weight: 210 lbs. BMI: 30.1. BP: 140/19 mmHg. RR: 14 rpm. PR: 88

4. bpm. Temp: 98.8 F SpO2: 99% RA.
General Survey: Alert and oriented x3. Well-developed, well-groomed, has moderate distress
from pain. The patient is corporative and understanding.
Skin: No rashes or lesions. Good skin turgor. No abrasions noted on the right knee. No
erythema.
Head/Neck: Head is normocephalic and atraumatic. Neck is free of masses and is symmetric. No
deviations in trachea noted. Complete ROM upon flexion, extension, and rotation. No tenderness
upon palpation.
Lungs: Clear to auscultation and percussion bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2; no S3, S4, or murmurs. Peripheral
pulses are 2+ and symmetrical.
Lower Extremities: No clubbing, cyanosis, or edema. No calf tenderness.
Musculoskeletal (Spine): No swelling, bruising or erythema noted. Moderate paraspinal muscle
spasms palpated bilaterally in the lumbar region, including the spinous processes. Lumbar range
of motion is slightly limited in flexion and extension due to pain. Straight leg raise test is
negative bilaterally.
Neurological: Normal sensation in bilateral extremities. Muscle strength is 5/5 bilaterally. Deep
tendon reflexes are 2+ and symmetric. Plantar reflexes are downgoing bilaterally. Gait is normal
on exam.

Assessment
Tests ordered: Complete Blood count to rule out infection.
Imaging test ordered: Cinsidering X-ray of lumbar spine if symptoms persist. If not conclusive,
will consider MRI of lumbar spine for further evaluation with no contrast.
Presumptive Dx:
Acute Lumbar Strain/Sprain (ICD-10 Code: M54.5 – Low back pain):
The patient presents with acute onset of low back pain that began after lifting heavy boxes,
which is a common mechanism for lumbar strain or sprain. The pain is localized to the lower
back and radiates to the buttocks and posterior thighs, consistent with a mechanical or
musculoskeletal source. There are no associated neurological deficits such as numbness, tingling,
muscle weakness, or bowel/bladder dysfunction, which helps rule out more serious causes like
disc herniation with nerve compression. On the physical exam, there is notable paraspinal muscle

5. spasm, tenderness, and limited lumbar range of motion, particularly in flexion and extension, all
of which support a diagnosis of soft tissue injury. The straight leg raise test is negative, further
reducing the likelihood of other diagnosis. Given the patient's age, activity, and symptom pattern,
acute lumbar strain is the most likely diagnosis.
Differential diagnosis: ICD-10 Code: M54.16 – Radiculopathy, lumbar region
The patient's pain radiates from the lower back to the buttocks and posterior thighs bilaterally,
following the typical distribution of the sciatic nerve. Although there are no sensory or motor
deficits, early nerve root irritation from a mild disc bulge or inflammation may be presented in
this way. A negative straight leg raise does not fully exclude radiculopathy making me to
consider given the radiation pattern and mechanism of injury a possible differential diagnosis.
ICD-10 Code: M51.26 – Other intervertebral disc displacement, lumbar region
The patient’s history of heavy lifting is a common precipitating factor for intervertebral disc
herniation or protrusion. Although there are no current neurological deficits, the radiation of pain
to the buttocks and posterior thighs, along with functional limitations, may represent early signs
of a discogenic origin. While the physical exam findings—particularly paraspinal muscle spasm
and a negative straight leg raise—are more consistent with a muscular strain, an intervertebral
disc disorder remains an important consideration, especially if symptoms fail to improve or
progress over time. The absence of positive neurological signs at this point suggests no
significant nerve root compression.
Lab and imaging results are pending as of 06/05/2025 6:30pm.

Problems from the Subjective:
 Acute onset of lower back pain after lifting heavy boxes
 Pain radiates bilaterally to the posterior thighs
 Pain is aggravated by standing, bending, and walking
 Pain interferes with sleep
 Described as sharp and achy
 Severity rated at 9 out of 10
 Denies numbness, tingling, or weakness
 No prior history of similar back pain episodes
Objective findings: Overweight: BMI is 30.1, palpable lumbar paraspinal muscle spasm,
negative straight leg test, absence of neurological deficits (thus ruled out Sciatica nerve
complications).

6. List of differential Dxs: Radiculopathy in lumbar region, Other intervertebral disc displacement,
lumbar region (reasoning is described above).
Pt has a current premorbid medical condition: HTN. I will keep monitoring the progress with
the current Metoprolol treatment.
PLAN
Disposition:
Patient is stable and I discharged him home with supportive management for acute low back
pain.
Labs/Imaging:
No immediate imaging is required at this time. If symptoms persist beyond six weeks or worsen,
consider lumbar spine X-ray or MRI to evaluate for structural abnormalities.
Medications:
Rxed Acetaminophen 500 mg PO every 6 hours as needed for pain relief. NSAIDs were avoided
due to the patient’s history of hypertension and current use of metoprolol, which may interact
and increase blood pressure.
Supportive Care:
Patient was advised to use heat therapy (heating pad) to relieve muscle tension and reduce
spasms. Recommended gentle stretching and beginning lumbar stabilization exercises as
tolerated. Strict instructions were given to avoid heavy lifting, repetitive bending, or activities
that aggravate the pain.
Referrals:
Consider referring to physical therapy for guided rehabilitation focused on strengthening,
flexibility, and posture correction if the pain persists.
Chronic Conditions:
The patient is to continue metoprolol 100 mg daily for hypertension. No interactions noted with
acetaminophen. Lifestyle counseling provided on weight reduction and dietary changes to help
decrease mechanical stress on the lumbar spine.
Patient Education:
Discussed the typical course of recovery, with most patients experiencing gradual improvement
over 2–4 weeks with rest, supportive care, and physical therapy. Emphasized the importance of
proper body mechanics and lifting techniques moving forward. Educated the patient on red flag
symptoms—such as new or worsening numbness, bowel/bladder incontinence, saddle anesthesia,
unexplained weight loss, or fever—and instructed to seek immediate medical attention if any
develop.

7. Preventive Care:
Reinforced safe lifting techniques to prevent recurrence. Encouraged ongoing use of seatbelt and
sunscreen, which the patient already practices. Discussed long-term benefits of healthy eating,
weight management, and regular low-impact exercise for overall back health and cardiovascular
support.
Barriers to Care:
Patient reports no barriers to accessing medical care or medications. He has reliable insurance
coverage and follows up regularly with his providers.
Follow-Up:
Instructed to follow up with his primary care provider in 2 weeks for reassessment of symptoms.
Also to attend physical therapy sessions as scheduled. Advised to return to the emergency
department immediately if any red flag symptoms arise.
Works Cited:
Dydyk AM, Khan MZ, Singh P. Radicular Back Pain. [Updated 2022 Oct 24]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK546593/
Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain [Internet].
Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Feb. (Comparative
Effectiveness Reviews, No. 169.) Available from:
https://www.ncbi.nlm.nih.gov/books/NBK350276/
Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American
College of Physicians; Denberg TD, Barry MJ, Boyd C, Chow RD, Fitterman N, Harris RP,
Humphrey LL, Vijan S. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back
Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med.
2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789.


Electronic Signature, Siranush Gharibyan, PA-S 06/05/2025 at 7:30 pm
Supervising Physician: First Name, Last Name, MD/DO
Used Ai for grammar correction.