Comprehensive SOAP Template
Patient Initials: ___RQ____ Age: _42______ Gender:
____Male___
SUBJECTIVE DATA:
Chief Complaint (CC): ‘My back is killing me. I can’t take it anymore.’
History of Present Illness (HPI): A 42-year-old male (RQ) reported to the clinic with
complaints of pain in his lower back that have persisted for the last one month. RQ stated
that the pain has shifted from mild to chronic in the last 4-5 weeks. The pain radiates
toward his hips and is more of a throbbing ache. The dull ache can last close to 50-60
minutes per episode. At times the pain goes on for 3-4 hours dependent on the activities
he is engaged. The pain ranges from 8/10 to 3/10 for when he does activities and when at
rest respectively. RQ also stated that the pain gets worse at night and hinders him from
sleeping well. The patient stated that the pain began after sliding on his son’s toy and
falling back first on the concrete front porch. He said that there was some bruising 2 days
later though now disappeared. However, the pain has continued to persist. The patient
noted that simple tasks such as picking anything from the floor and getting in and out of
his vehicle are becoming difficult to achieve. He also said that he is no longer to pick up
his four year old toddler nor carry him on his shoulders like he previously would.
Medications: Topical CBD cream, Tylenol, and Aleve
Allergies: KNDA
Past Medical History (PMH): Anxiety, Chronic Sinusitis
Past Surgical History (PSH): None
Sexual/Reproductive History: Married since 2006
Personal/Social History: Patient has a wife and two sons (4 and 6 years old)
Immunization History: Up to date with DTAP, MMR, Tetanus, Flu vaccine, and HEP B
series
Significant Family History: Father has diabetes. Mother has HTN and Depression.
Both paternal and maternal are deceased. Paternal grandfather had diabetes while the
paternal grandmother had HTN. Maternal grandmother hhad breast cancer while the
maternal grandfather had prostate cancer.
Lifestyle: Patient does not smoke or use any illegal drugs. Takes 2 bottles of beer 3 times
a week. RQ spends his weekend playing basketball and soccer but has not done so since
the back injury. The patient also likes to hike twice a year and participates in local ski
competitions upstate.
Review of Systems:
General: No weight gain or losses; no weaknesses, fatigue, or fevers. Patient ppeard
clean and oriented. He answered all questions appropriately.
HEENT: No headaches, dizziness or vertigo. No vision changes, Pain, Redness, Blurry
or double vision. No Tinnitus, drainage or hearing aches. No nose stuffiness, Itching,
Nosebleeds, Discharge, Hay fever, cold, change in sense of smell, or current Sinus pain.
No bleeding gums; tooth ache, mouth pain, lesions in mouth or tongue, last dental exam;
dentures; sore tongue; sore throats; dry mouth; hoarse; altered taste or tonsillectomy;
Neck: No Lumps; swollen glands; goiter; enlarged or tender nodes, pain; limitation of
motion; neck stiffness
Breasts: Deferred
Respiratory: No cough, hemoptysis; wheezing; dyspnea; pleuritic pains; toxin or
pollution exposure; any H/O lung disease; last Chest x-ray, or TB skin test
Cardiovascular/Peripheral Vascular: No chest pain or discomfort; dyspnea;
palpitations; orthopnea; cyanosis, edema, nocturia; hypertension, H/O murmurs, CAD or
anemia
Gastrointestinal: No Appetite loss; nausea/emesis; jaundice; dysphagia; pain; heartburn;
belching/flatulence; hematochezia; loss in bowel habits; melena; constipation;
hemorrhoids; food intolerance; or diarrhea
Genitourinary: No increase in frequency; urgency; nocturia; dysuria; incontinence; or
hematuria
Quality Work
Unlimited Revisions
Affordable Pricing
24/7 Support
Fast Delivery