SOAP (custom)

10:00 AM 01 November 2024 Subjective: - Patient presents today with complaints of lower back pain and stiffness, following a fall two days ago. - Pain is located in the lumbar region, described as a dull ache, and rated as 6/10 in severity. It is worse with movement and prolonged sitting, and improves with rest. - Symptoms are aggravated by bending and twisting. Patient has tried over-the-counter pain relievers with minimal relief. - The pain has gradually worsened since the fall. - No previous episodes of similar back pain. - The pain is affecting the patient's ability to work and perform daily activities. - Associated symptoms include muscle spasms in the lower back. Past Medical History: - Patient has a history of mild osteoarthritis in the knees. No relevant surgical history. No previous physiotherapy. - Patient is a non-smoker and drinks alcohol occasionally. Works as a desk-based office worker. - No family history of back problems. - No known exposure history. - Immunization status up to date. - Other: Patient reports feeling anxious about the injury. Objective: - Vitals signs: Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min. - Physical examination: Observation: Patient walks with a guarded gait, slight forward lean. Palpation: Tenderness to palpation over the lumbar paraspinal muscles. Range of motion: Lumbar flexion limited to 45 degrees, extension limited to 10 degrees, lateral flexion limited bilaterally. Neurological: Sensation intact in lower extremities. Strength 5/5 in lower extremities. - Investigations with results: None. Treatment: - Soft tissue massage to lumbar paraspinal muscles in prone position for 10 minutes. - Spinal mobilisation to lumbar spine. - Patient educated on proper posture and body mechanics. - Exercises/home exercise plan: Patient instructed on a home exercise program including gentle lumbar stretches and core strengthening exercises. Assessment: - Likely diagnosis: Acute lumbar strain. - Differential diagnosis: Lumbar sprain, possible facet joint dysfunction. Plan: - Investigations planned: None. - Treatment planned: Continue with physiotherapy sessions twice a week for the next two weeks. Reassess in two weeks. - Relevant other actions such as counselling, referrals etc: Provide patient with an information sheet on back pain management.