Assessment Task 2: Problem-Focused SOAP Note for Low Back Pain Case Study

Course: Family Medicine/Primary Care Clerkship or Advanced Health Assessment

Assignment Overview

Students complete a comprehensive, problem-focused SOAP note based on the Aquifer Family Medicine Case 10: 45-year-old male patient presenting with low back pain. The note demonstrates clinical reasoning skills, accurate documentation, and evidence-based management in a primary care setting.

Learning Objectives

• Construct a structured SOAP note using subjective and objective data from the case.
• Identify red flags and develop an appropriate differential diagnosis for low back pain.
• Perform virtual physical examination findings and interpret relevant tests.
• Propose an evidence-based plan including non-pharmacologic and pharmacologic options, patient education, and follow-up.
• Apply current clinical practice guidelines for acute or subacute low back pain management.

Instructions

1. Review the Aquifer case details, including history, physical exam findings, and any available test results.
2. Use the standard SOAP format (Subjective, Objective, Assessment, Plan).
3. Include at least three differential diagnoses in the Assessment section, ranked by likelihood, with supporting rationale.
4. Justify the primary diagnosis using subjective and objective evidence.
5. Develop a detailed Plan that addresses medications (if indicated), non-medication treatments, further testing (or rationale against imaging), patient education on self-management, and follow-up instructions.
6. Reference relevant guidelines (e.g., ACP or similar) to support recommendations.
7. Word count: 1050–1400 words (excluding references).
8. Use APA or Harvard referencing style.
9. Submit via the learning management system by the due date.

Grading Rubric

• Subjective section completeness and accuracy: 20%
• Objective section detail and relevance: 20%
• Assessment (differentials, primary diagnosis, reasoning): 25%
• Plan (evidence-based, comprehensive, patient-centered): 25%
• Organization, clarity, grammar, and referencing: 10%

Patients with acute low back pain often recover within weeks through conservative measures like staying active and using heat therapy. Clinicians screen for red flags such as unexplained weight loss or neurological deficits to rule out serious pathology. Evidence-based plans prioritize nonpharmacologic interventions before considering NSAIDs for persistent symptoms.

Learning Materials/Resources

Oliveira, C.B., Maher, C.G., Pinto, R.Z., Traeger, A.C., Lin, C.W.C., Chenot, J.F., van Tulder, M. and Koes, B.W. (2018) ‘Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview’, European Spine Journal, 27(11), pp. 2791–2803. doi:10.1007/s00586-018-5673-2.

Korownyk, C.S., Montgomery, L., Young, J., Moore, S., Singer, A.G., MacDougall, P., Dartnell, J., Babenko, O., Lindblad, A.J., Ton, J. and Perry, D. (2022) ‘PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care’, Canadian Family Physician, 68(3), pp. 179–190. doi:10.46747/cfp.6803179.

George, S.Z., Fritz, J.M., Silfies, S.P., Schneider, M.J., Beneciuk, J.M., Lentz, T.A., Bishop, M.D., Thackeray, A. and Bialosky, J.E. (2021) ‘Interventions for the management of acute and chronic low back pain: Revision 2021’, Journal of Orthopaedic & Sports Physical Therapy, 51(11), pp. CPG1–CPG60. doi:10.2519/jospt.2021.0304.

Zhou, T., Salman, D. and McGregor, A.H. (2024) ‘Recent clinical practice guidelines for the management of low back pain: a global comparison’, BMC Musculoskeletal Disorders, 25(1), p. 344. doi:10.1186/s12891-024-07468-0.