SOAPIE

Subjective: - Patient reports experiencing lower back pain for the past two weeks, exacerbated by prolonged sitting and bending. States pain is a constant ache, rated 6/10, with occasional sharp spasms. Reports no specific injury, but attributes onset to increased gardening activity. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - No previous surgeries. History of lower back pain in the past, resolved with physiotherapy. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Currently taking Ibuprofen 400mg as needed for pain. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Patient is a retired teacher, lives at home with her husband. Non-smoker, drinks alcohol occasionally. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - No known allergies. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Objective: - Blood Pressure: 130/80 mmHg, Heart Rate: 78 bpm, Respiratory Rate: 16 breaths/min. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Observation: Patient ambulates with a slight limp. Palpation reveals tenderness over the lumbar paraspinal muscles. Range of motion (ROM) limited in lumbar flexion and extension. Positive slump test. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - No recent imaging or lab results available at this time. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Assessment: - Lumbar strain. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Patient presents with acute lower back pain secondary to lumbar strain. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan: - Initiate physiotherapy treatment plan including manual therapy, therapeutic exercises (core strengthening and lumbar stabilisation), and modalities (heat/ice). Review home exercise program. Schedule follow-up appointment in one week. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Educate patient on proper posture, body mechanics, and activity modification. Provide written home exercise program. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Intervention: - Performed manual therapy techniques including soft tissue mobilisation and joint mobilisation. Provided instruction and supervised initial core strengthening exercises. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Evaluation: - Patient reports slight improvement in pain levels following treatment. Re-evaluation of ROM and pain levels will be conducted at the next visit. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)