Musculoskeletal disorders soap note

Episodic/Focused SOAP Note Template Patient Information: Initials Y.S Age 46 Sex Female Race African American S. CC (chief complaint) “I am having lower back pain” HPI: 46 year old African American female presents to the clinic for return to work visit. Employee had a fall on 6/25/19 while running to her car from home to pick up groceries. She reported she missed couple of steps and landed on her buttocks. Employee stated she had pulling back pain 7/10 next day and took Advil 200mg and went to see her PCP when the pain did not subside. PCP ordered Tramadol 50mg every 8-12hours prn. She reported she last took tramadol prn dose on 6/30/19 morning. Employee reported she has been out of work for 4 days. Current Medications: Tramadol 50mg by mouth Q8-12 hrs as needed, Zoloft 100mg by mouth QD. Allergies: NKDA PMHx: Back injury couple of years ago, Depression Sx Hx: None Soc Hx: Employee works as an housekeeper in the hospital. Her job entails lifting and pushing ROS: GENERAL: No weight loss, fever, chills. Employee reports weakness and fatigue from use of tramadol. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: Grossly intact CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Denies burning on urination. Last menstrual period 06/11/2019. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Employee reported lower back pain 5/10. Limited ROM with muscular assessment due to back pain. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. VS: 117/82, 81, 98.4, 18, 96% RA General: Employee is Ax0x4, calm and cooperative. Ambulates with steady gait. Diagnostic results: X-ray? A. Primary Diagnosis – Muscle spasm ? Differential Diagnoses ? ? ? P. – Employee was asked to clarify medical clearance with restriction with PCP – Employee is not cleared to return to work – Physical therapy referral