Physical Therapy SOAP Note Examples

SUBJECTIVE:  The patient is a (XX)-year-old male. The patient came in for back pain. Before shift change, he was initially evaluated by Dr. John Doe for back pain for the last two days. He said it was in the mid back, going down to the left knee, with some paresthesias in the feet and numbness in the feet. Movement, remaining still, and laying on a side seems to relieve pain. Lying directly on his back increases the pain. No problems with urination. No fever or chills. No nausea, vomiting or diarrhea. No abdominal pain.

PAST MEDICAL HISTORY:  Significant for back injury. He had anterior fusion of L3-L3 in the past. He has had multiple episodes, about one a month, since the surgery of exacerbation of his chronic back pain. This typical pain pattern with numbness and radiation down the leg, he states, is nothing unusual for the last multiple episodes. He has had no bladder or bowel dysfunction.

SOCIAL HISTORY:  He is a smoker.

OBJECTIVE:  The patient is alert, in no acute distress, obviously uncomfortable however. C-spine is negative. He is tender over the mid back, L2 through L4 with paravertebral muscle spasm that is palpable, also quite tender. Decreased range of motion. The patient is alert and orientated x3. No motor deficits. Strength 5/5. He does have diminished left patellar reflex. Decreased sensory on the left great and little toe, medial aspect of the foot and lateral aspect on the plantar surface of the foot. Sensory is intact.

INTERVENTION:  At this time, we suggested doing the MRI that Dr. John Doe had suggested. The patient instead wishes to follow up with another facility and get the MRI done there, which we agreed with, as long as he does it in a rapid fashion.

1.  Acute myofascial strain.
2.  Acute exacerbation of chronic low back pain.

PLAN:  Percocet 5 mg 1-2 q.4-6 hours as needed for pain, Soma one three times a day, Indocin SR 75 mg b.i.d. with food. Follow up with the specialist who did his back surgery for reevaluation of his increasing back pain over the last several years. Any acute problems, recheck sooner. Any problems with bladder or bowel, recheck immediately.

SUBJECTIVE:  This (XX)-year-old male came in with an injury to his right shoulder yesterday afternoon at work. He was resting and he tweaked the shoulder. He is not sure of the mechanism. He was sore all of last night. He pulled on a door handle, pushing its handle down and pulling it straight back and had quite a bit of pain when he did this. He came in with increased pain. He is right handed. Prior injury two years ago to the shoulder. He had injection by Dr. John Doe after an MRI. MRI results were reviewed and showed a biceps tendinitis.

OBJECTIVE:  The patient is alert and in no acute distress. The patient is tender over the soft tissue of the shoulder. No swelling or ecchymosis. No deformity. The patient is point tender over the biceps tendon. He is also tender over the lateral deltoid and over the supraspinatus tendon area. Both are equally tender. Pain with biceps range of motion. Also, has painful range of motion in abduction and internal rotation, both active and passive. He does have grip strength. No evidence of rotator cuff tears at this time. Distal neurosensory examination is intact. Motor is intact. Strength is symmetrical. No vascular compromise. C-spine is negative. Trapezius muscles are negative.

Right shoulder x-ray reviewed by Dr. Jane Doe is negative.

INTERVENTION:  At this time, we discussed injection versus anti-inflammatory medications. We are going to start with conservative therapy.

1.  Biceps tendinitis, right shoulder.
2.  Supraspinatus tendinitis, right shoulder.

PLAN:  The patient did not wish any narcotic pain medication. Ibuprofen 800 mg q.6 hours. Ice to the shoulder. Recheck in 5-7 days, sooner if worse. If not improved, consider injections.