SOAP Notes - Homework · Healthcare Hustlers

SOAP Notes - Homework

Good morning! Sorry my delay on last week homework! 🫣

S – A 75-year-old male presented to the clinic experiencing lower back pain the past 15 days, which worsens when standing. He also related weakness in both legs.

O – Pain level is rated at 5 out of 10, with limited forward flexion and lateral bending. Strength 4/5 in lower extremities. Gait with difficulty. Positive for straight leg raise test on the right side.

A – Pain and discomfort in the lower back, decreased ROM, muscle weakness and impaired gait. Diagnosis: Lumbar strain with associated muscle spasm.

P – Improve lumbar flexibility and ROM. Strengthen lower back and legs muscles. Normalize gait.

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