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SOAP Note on Muscular and Skeletal Body System

Please assist in preparing SOAP notes either in a muscular or skeletal body system of a fictional patient of not less then 4 paragraphs including medical terms with suffixes, roots, and prefixes. Then write a summary of the findings rather then medical diagnosis.

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S: Since the last visit the patient has experienced a decrease in her lumbar spine pain. She reports that the pain continues to be achy but is more localized to the region of the right posterior superior iliac spine (PSIS). She is no longer experiencing the diffuse pain along her distal right lower extremity. When questioned about her exercise program she admits that she has been doing the last taught set of Swiss ball exercises only once per day, instead of the twice per day as was recommended. There has been no change in her health or medical status since her last visit to this office.

O: Vitals: HR = 72 bpm, .BP = 120/72, RR = 12/m, temperature = 98.6
The following orthopedic tests were performed ...

Solution Summary

Example of a SOAP note involving the musculoskeletal system.