Merced College

• ALLH 67

• SOAP NOTE SCENARIOS Scenario #1 Patient is a 32 year old African American female with chief complaints of low back pain. The pain began suddenly when she stood up from a chair. There was no specific trauma associated with the onset of pain. The pain was described as sharp, bilateral pain in her lower back. That was rated 6 out of 10. The pain is consistent but gets worse when she stands up from a sitting or lying position. It is relieved by sitting or lying. Patient has taken over the counter NSIADS for pain but they provided no relief. Patient does not recall any specific trauma to her back, but she was lifting a heavy suitcase while traveling 3 days prior to the onset of pain. She walked into therapy very slow and cautious and commented that she was “slow as a snail”. Her initial active thoracic spine flexion was 45 degrees and extension was 10 degrees. She has been approved for 3 physical therapy sessions, and we will be working on decreasing inflammation along with mild stretches to increase flexibility. Scenario #2 Patient is a 16 year old male Hockey and Lacrosse player came in with a right clavicle fox. MOI: He was going into the corner of the rink and another kid put him in a headlock, kicked him, and landed on top of his