Advanced Health Assessment: SOAP Note and Evidence-Based Management of Acute Low Back Pain

Assessment Task Overview

Prepare a structured SOAP note and a short evidence-based analysis for an adult patient presenting with acute low back pain in a primary care setting. Draw on current clinical guidelines to demonstrate advanced health assessment skills, diagnostic reasoning, and safe management planning for non-specific low back pain.

The task focuses on accurate patient encounter documentation, appropriate use of red-flag criteria, and selection of conservative versus referral-based interventions consistent with contemporary low back pain practice guidelines.

Assignment Type, Length and Weighting

• Type: Written clinical assessment / case-based assignment (SOAP note plus analytic commentary)
• Length: 2,000-word paper (approximately 4–6 pages), excluding title page and reference list
• Weighting: Typically Assessment 2 or 3 in an Advanced Health Assessment / Adult Primary Care / Family Practice / NP unit (check your specific subject outline)

Case Scenario

You are working in an adult primary care or family medicine clinic. A middle-aged adult (approximately 40–55 years) presents with acute low back pain impacting work and daily function. Relevant details include onset after a common precipitating activity, absence or presence of red flags, and psychosocial factors influencing pain and recovery.

Use the back pain teaching material and patient encounter documentation structure from your learning resources (including the low back pain case in paste.txt) as the clinical foundation.

Task Instructions

Part A: SOAP Note (Approx. 1,200–1,400 words)

Develop a comprehensive SOAP note for the low back pain encounter using a structured format consistent with advanced health assessment practice. Use clear headings and concise clinical language.

Subjective (S)

• Chief Complaint (CC): Record the patient’s presenting concern in their own words in quotation marks.
• History of Present Illness (HPI): Describe onset, location, duration, character, aggravating/alleviating factors, timing, and associated symptoms of the low back pain.
• Red Flags: Explicitly document presence or absence of symptoms such as night pain, unexplained weight loss, fever, trauma, bowel/bladder dysfunction, saddle anesthesia, progressive neurologic deficits, or history of cancer/infection.
• Past Medical History (PMH): Include chronic illnesses, surgeries, previous back injury, osteoporosis risk, steroid use, and psychiatric history.
• Medications and Allergies: List all current medicines (dose, frequency, indication) and allergies/intolerances, noting potential interactions for pain management.
• Family History: Summarise any family patterns of musculoskeletal disease, osteoporosis, malignancy, rheumatologic conditions, or relevant chronic illnesses.
• Social History: Capture occupation, work demands, lifestyle, physical activity level, smoking, alcohol, other substance use, and psychosocial stressors that may affect back pain course.
• Review of Systems (focused): Briefly document pertinent positives and negatives across general, musculoskeletal, neurologic, genitourinary, and constitutional systems.

Objective (O)

• Vital Signs: Record weight/BMI, blood pressure, heart rate, respiratory rate, and temperature.
• General Appearance: Describe overall appearance, distress level, mobility, and affect.
• Back and Musculoskeletal Exam: Document inspection (posture, scoliosis, kyphosis, lordosis), palpation (tenderness, muscle spasm), and range of motion in flexion, extension, and lateral bending.
• Neurologic Exam: Record lower extremity strength, reflexes (patellar, Achilles), sensation by dermatomes, and any gait abnormalities (heel/toe walking, stoop test).
• Special Tests: Include straight leg raise (and crossed SLR if indicated), FABER test, and any additional tests performed, noting positive or negative findings.
• Other Systems as Indicated: Document key abdominal, vascular, and rectal findings only if clinically relevant or red flags are present.

Assessment (A)

• Identify one primary working diagnosis (for example, acute mechanical low back strain or non-specific low back pain) supported by your subjective and objective data.
• List at least two additional differential diagnoses (e.g., herniated disc with radiculopathy, spinal stenosis, vertebral fracture, malignancy, infection, ankylosing spondylitis, visceral referral) and justify why they are more or less likely in this case using red-flag and exam findings.
• Comment on prognostic factors, including psychosocial risk and occupational demands, that may influence symptom persistence or functional limitation.

Plan (P)

• Diagnostics: Specify if imaging or laboratory tests are indicated at this visit based on guideline-supported indications (e.g., severe or progressive neurologic deficit, trauma, suspicion of cancer or infection, or failure of conservative treatment).
• Pharmacologic Management: Propose a first-line regimen using NSAIDs and/or acetaminophen and, where appropriate, short-term muscle relaxants, with brief rationale and safety considerations.
• Non-Pharmacologic Management: Outline advice on activity, early mobilisation, physical therapy referral, manual therapy, or other supported non-invasive approaches.
• Patient Education: Summarise key messages you would provide about prognosis, expected course, red-flag symptoms requiring urgent review, and strategies to prevent recurrence.
• Follow-Up: Indicate a realistic follow-up interval, outcome measures (pain, function, work status), and triggers for re-evaluation or referral to spine specialist or multidisciplinary pain services.

Part B: Evidence-Based Commentary (Approx. 600–800 words)

Write a concise analytic section linking your clinical decisions in the SOAP note to current evidence and guidelines for non-specific low back pain in primary care.

1. Briefly discuss the epidemiology and typical course of acute low back pain and explain why most cases can be managed conservatively without early imaging.
2. Explain your use or avoidance of imaging and laboratory tests, citing guideline recommendations and known harms of unnecessary imaging (radiation exposure, incidental findings, cost, and anxiety).
3. Justify your choice of first-line pharmacologic and non-pharmacologic strategies using recent clinical practice guidelines or systematic reviews.
4. Outline how you screened for red flags and how those findings did or did not alter your management plan.
5. Comment briefly on how you would individualise care for patients with higher psychosocial risk or persistent symptoms despite initial conservative therapy.

Formatting and Submission Requirements

• Length: 2,000 words total (SOAP note plus commentary) ±10%
• Format: Double-spaced, 12-point readable font, standard margins; headings and subheadings encouraged
• Referencing: Minimum of five recent, peer-reviewed sources (2018–2026) in Harvard style
• Academic integrity: Use your own wording; do not copy learning resources, clinical guidelines, or sample notes verbatim

Marking Criteria / Rubric

1. Subjective and Objective Data (30%)

• Comprehensive and relevant subjective history including red-flag screening and psychosocial factors
• Structured, clinically appropriate physical examination findings, with clear documentation of musculoskeletal and neurologic assessment
• Use of professional language and logical organisation of the SOAP sections

2. Diagnostic Reasoning and Differentials (25%)

• Clear, evidence-aligned primary diagnosis consistent with the case scenario
• Plausible differentials that reflect mechanical, visceral, and serious spinal causes of back pain, with concise justification for each choice
• Appropriate use of red-flag information in ruling in or ruling out urgent pathology

3. Management Plan and Evidence Use (30%)

• Coherent, guideline-consistent plan integrating pharmacologic and non-pharmacologic strategies
• Sound, succinct rationale for the use or avoidance of imaging and further investigations
• Specific, realistic patient education and follow-up arrangements that support function and self-management

4. Scholarship, Referencing and Presentation (15%)

• Logical flow, clarity of writing, and adherence to academic style
• Accurate in-text citations and reference list in Harvard format, using current peer-reviewed sources
• Correct spelling, grammar and professional presentation suitable for senior undergraduate or graduate-level work

Low back pain in middle-aged adults is most often non-specific and mechanical, with a favourable natural history when managed with early activity, reassurance, and simple analgesia. Careful documentation in a structured SOAP note format allows clinicians to connect patient-reported symptoms with focused examination findings and guideline-based decisions about imaging and referral. An evidence-informed plan usually emphasises NSAIDs or acetaminophen, graded return to usual activities, and targeted physical therapy while reserving advanced imaging for those with red flags or persistent disabling symptoms. Clear patient education about prognosis, self-management strategies, and warning signs helps prevent chronicity and supports shared decision-making in primary care.

References

1. Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M. et al. (2020) ‘Nonpharmacologic therapies for low back pain: A systematic review for an American College of Physicians clinical practice guideline’, <i>Annals of Internal Medicine</i>, 172(3), pp. 218–230. Available at: https://doi.org/10.7326/M19-3610​

2. Oliveira, C.B., Maher, C.G., Pinto, R.Z., Traeger, A.C., Lin, C.W.C., Chenot, J.F. et al. (2019) ‘Clinical practice guidelines for the management of non-specific low back pain in primary care: An updated overview’, <i>European Spine Journal</i>, 28(11), pp. 2681–2692. Available at: https://doi.org/10.1007/s00586-019-06222-1​

3. Corp, N., Mansell, G., Stynes, S., Wynne-Jones, G., Mors, L., Hill, J.C. and van der Windt, D.A. (2021) ‘Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines’, <i>European Journal of Pain</i>, 25(2), pp. 275–295. Available at: https://doi.org/10.1002/ejp.1679​

4. George, S.Z., Fritz, J.M., Silfies, S.P., Schneider, M.J., Beneciuk, J.M., Lentz, T.A. et al. (2021) ‘Interventions for the management of acute and chronic low back pain: Revision 2021’, <i>Journal of Orthopaedic & Sports Physical Therapy</i>, 51(11), pp. CPG1–CPG60. Available at: https://doi.org/10.2519/jospt.2021.0304​

5. Skelly, A.C., Chou, R., Dettori, J.R., Turner, J.A., Friedly, J.L., Rundell, S.D. et al. (2018) ‘Noninvasive nonpharmacological treatment for chronic pain: A systematic review’, <i>Comparative Effectiveness Review</i> No. 209, Agency for Healthcare Research and Quality. Available at: https://effectivehealthcare.ahrq.gov/products/nonpharma-treatment-pain/research​