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Episodic/Focused Note Template

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Episodic/Focused Note Template

Patient Information:

Patient Initials: J.D.

Age: 35

Sex: Male

Race: White

S.

CC (chief complaint): “Chronic lower back pain worsened by heavy lifting.”

HPI:

J.D. is a 35-year-old White male presenting with chronic lower back pain. The pain began several years ago and has become progressively worse, particularly when engaging in heavy lifting. He describes the pain as “punching” in nature, with a severity of 7/10. The discomfort is localized to the lumbar region and occurs daily, accompanied by muscle spasms: Episodic/Focused Note Template.

The pain disrupts functional activities like repairing a vehicle. He has a known history of Scoliosis without a history of previous back surgery, trauma, or physical therapy. He has had three MRIs over the years, but no treatment was done. He does not admit bowel or bladder dysfunction or neurological deficits.

Current Medications:

Takes unspecified over-the-counter NSAIDs for pain.

Allergies:

No known drug or food allergies.

No environmental allergies were reported.

PMHx:

The medical history of this patient indicates the presence of scoliosis, unspecified (ICD-10: M41.9), a condition that causes curvature of the spine, which adds to mechanical lower back pain. Another condition he has is chronic low back pain (ICD-10: M54.5), aggravated by the impact of physical activity and muscle spasms. Immunization records are current, and a record of Tdap booster vaccination in the last five years is present.

Soc Hx:

The patient works as a mechanic, which is probably one of the reasons he repeatedly has back problems, as his job is physically demanding. His activity level is not very high, as evidenced by the fact that other than work, he hardly participates in activities other than running and playing with his children, which are both light activities. He does not take tobacco, alcohol, or illegal drugs.

He always observes safety measures such as using seat belts, maintaining smoke alarms, and avoiding texting behind the wheel. He also has a solid family support system, which can contribute to improved compliance with his care plan.

Fam Hx:

The father of the patient has hypertension, and the mother has osteoarthritis. None of the family members have been diagnosed with Scoliosis or any chronically progressing musculoskeletal disorder that may signify a genetic predisposition. There are no first-degree relatives who are reported to have had any neurological disorder, cancer, or genetic syndrome.

Such a family history indicates a moderate risk of age-related degeneration of the musculoskeletal system but does not point to a hereditary disorder of the spine that could be used as a direct explanation of his present state.

ROS:

GENERAL: No fever, weight loss, chills, or fatigue

HEENT: Uses glasses; no visual changes, headaches, nasal congestion, or sore throat

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, edema or palpitations

RESPIRATORY: No dyspnea or cough

GASTROINTESTINAL: No nausea, vomiting, or abdominal pain

GENITOURINARY: Normal urination, no incontinence

NEUROLOGICAL: Reports lumbar pain and spasms; no joint swelling or stiffness

MUSCULOSKELETAL: No numbness, tingling, or weakness

HEMATOLOGIC: No bleeding or bruising.

LYMPHATICS: No lymphadenopathy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

The patient was alert, cooperative, and not in acute distress on examination. Musculoskeletal examination showed local muscle tightness and some guarding in the lumbar paraspinal muscles that were tender to palpation without swelling or other deformities. There was a full range of motion with lower back discomfort.

Neurologically, his reflexes were symmetrical and intact, with bilateral muscle strength of 5/5 in the lower extremities. The sensation of light touch and pinprick was intact, and the straight leg raise test was negative. The patient’s gait and posture were symmetrical, with no sign of imbalance.

Diagnostic results:

The earlier MRI results had shown that there was mild curvature of the spine, indicating a possible case of Scoliosis, but there was no disc herniation or impingement of the nerves

A.

Primary Diagnosis

Chronic Low Back Pain (M54.5)

The patient complains of constant lower back pain that is worsened by movement and accompanied by muscle spasms, which conforms to the clinical presentation of chronic lower back pain (Farley et al., 2024). Radiological imaging did not reveal any acute pathology, and the neurological exam did not indicate severe red-flag symptoms like incontinence or limb weakness. These findings validate chronic low back pain as the most suited primary diagnosis.

Differential Diagnoses

Scoliosis, Unspecified (M41.9)

One differential diagnosis to be considered is Scoliosis. The patient has a known history of Scoliosis, which may lead to abnormal spinal curvature and contribute to mechanical lower back pain through musculoskeletal imbalance (Lacroix et al., 2023). Though the curvature observed on MRI was mild, it remains a relevant structural factor that could influence posture and muscle strain. However, the chronicity and presentation of symptoms align more closely with chronic low back pain than structural Scoliosis, which appears stable and uncomplicated.

Lumbar Muscle Spasm (M62.830)

The second differential diagnosis is Lumbar Muscle Spasm. The physical examination revealed mild guarding and localized muscle tightness, consistent with lumbar muscle spasms (Goel, 2024). Spasms may arise from overuse, poor biomechanics, or compensatory responses to chronic back issues. Despite their presence, the absence of acute injury or neurological deficits supports muscle spasms as a secondary rather than primary diagnosis.

Lumbar Radiculopathy (M54.16)

Lumbar radiculopathy typically presents with radiating pain, sensory loss, or motor weakness, none of which were noted in this patient (Alexander & Varacallo, 2024). Neurological exam findings were within normal limits; previous MRI scans did not show nerve root compression. These factors reduce the likelihood of radiculopathy as a primary diagnosis in this case.

Although less likely due to the absence of sensory loss or reflex changes, lumbar radiculopathy should be considered in recurrent or escalating pain. The preserved sensation and reflexes make this less probable.

Diagnostics

No additional diagnostic imaging is required at this time since the patient has undergone three previous MRIs, all of which showed mild Scoliosis without acute pathology such as disc herniation or nerve root compression. Further imaging will be reconsidered only if new neurological symptoms develop or if conservative management does not improve. The patient has been referred to physical therapy to begin a structured rehabilitation program to improve strength, flexibility, and function.

Pharmacologic management

The patient was advised to continue taking NSAIDs such as ibuprofen 400 to 600 mg orally three times a day as needed to manage inflammation and pain. In the case of persistent muscle spasms, a short course of a muscle relaxant such as cyclobenzaprine 5 mg orally three times daily was suggested (Khan & Kahwaji, 2023). These medications were discussed in terms of proper use, potential side effects such as gastrointestinal irritation or drowsiness, and the importance of avoiding long-term reliance on pharmacological therapy.

Non-Pharmacologic and Alternative Therapies

The essential part of the management plan would be to initiate a regimen of guided physical therapy sessions, which will focus on postural enhancement, core strength, and flexibility. The patient was educated about lifting objects that put less pressure on the back and performing stretching exercises at home daily (Washmuth et al., 2022). Based on comfort and response, heat and cold therapy were recommended for symptomatic relief. Additionally, if traditional therapies prove insufficient, chiropractic adjustments and acupuncture were discussed as complementary options.

Follow-Up

The patient is scheduled to return in four weeks to reassess symptoms, physical therapy progress, and medication response. A sooner follow-up is advised if he experiences worsening pain, functional decline, or any signs of neurologic impairment. At the next visit, further strategies for long-term pain control, including advanced therapies or referral to pain management, will be discussed if necessary. The follow-up will ensure appropriate modifications to the care plan and reinforce adherence to non-pharmacologic interventions.

Reflection

In retrospect, I would consider early referral to physical therapy when the initial MRIs were performed rather than delaying intervention. In future cases, I will emphasize the importance of conservative management earlier in the treatment plan. I also learned the value of assessing the patient’s lifestyle and occupational risks more thoroughly during history taking, as his role as a mechanic exacerbates his condition.

For health promotion, education on ergonomic workplace practices, maintaining physical activity, and core strengthening is vital in managing chronic musculoskeletal conditions, especially in a young, active male from a non-smoking, supportive household. His socioeconomic status appears stable, allowing adherence to follow-up and therapy recommendations. 

References

Alexander, C. E., & Varacallo, M. (2024, February 27). Lumbosacral Radiculopathy. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430837/

Farley, T., Stokke, J., Goyal, K., & DeMicco, R. (2024). Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment. Life, 14(7), 812. https://doi.org/10.3390/life14070812

Goel, A. (2024). Chronic muscle pain and spasm hallmarks of spinal instability. Journal of Craniovertebral Junction and Spine, 15(3), 263–265. https://doi.org/10.4103/jcvjs.jcvjs_137_24

Khan, I., & Kahwaji, C. I. (2023, August 28). Cyclobenzaprine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513362/

Lacroix, M., Khalifé, M., Ferrero, E., Clément, O., Nguyen, C., & Feydy, A. (2023). Scoliosis. Seminars in Musculoskeletal Radiology, 27(5), 529–544. https://doi.org/10.1055/s-0043-1772168

Washmuth, N. B., McAfee, A. D., & Bickel, C. S. (2022). Lifting techniques: Why are we not using evidence to optimize movement? International Journal of Sports Physical Therapy, 17(1). https://doi.org/10.26603/001c.30023

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Question 

Episodic Visit: HEENT Focused Note

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks, and complete an Episodic/Focused Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this week’s Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Episodic/Focused Note Template

Episodic/Focused Note Template

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

To prepare:

Assignment:

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