Create a SOAP note for a 29‑year‑old male undergoing reassessment of Alpha‑Stim therapy who reports excellent control of anxiety, depression, and insomnia without side effects, and now presents with acute mechanical low‑back pain related to improper bending or calisthenics, evaluated via audio‑only telehealth.

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SOAP Note: 29-Year-Old Male – Alpha-Stim Reassessment with New Low Back Pain

Subjective

Chief Complaint: Reassessment of Alpha-Stim therapy; new onset low back pain

History of Present Illness:

  • Alpha-Stim therapy: Patient reports Alpha-Stim has been "wonderful" for managing anxiety, depression, and insomnia 1, 2
  • Side effects: Denies dizziness, headache, or skin irritation 2
  • Overall health: No new changes reported
  • Low back pain:
    • Onset: Started last month (approximately 4 weeks duration)
    • Character: Aching pain
    • Mechanism: Improper bending or calisthenics when reaching or bending 3
    • No radiation below the knee reported
    • No neurological symptoms (weakness, numbness, bowel/bladder dysfunction) mentioned 3, 4

Mental Status (Audio-Only Telehealth):

  • Speech: Coherent
  • Thought process: Appropriate

Objective

Telehealth Limitations: Audio-only visit limits physical examination 3

Mental Status Examination:

  • Speech: Normal, coherent
  • Thought process: Organized and appropriate
  • Mood: Appears improved on Alpha-Stim therapy 2

Physical Examination: Unable to perform comprehensive musculoskeletal examination via audio-only format 3

Assessment

  1. Anxiety, depression, and insomnia – well-controlled on Alpha-Stim cranial electrotherapy stimulation

    • Patient demonstrates sustained clinical response to Alpha-Stim therapy, consistent with evidence showing 47.8% remission rates at 24 weeks in GAD patients 2
    • No adverse effects reported, which aligns with the well-tolerated safety profile of CES 1, 2
    • Continue current regimen given excellent symptomatic control 2

  2. Acute mechanical low back pain (approximately 4 weeks duration)

    • Likely nonspecific low back pain based on mechanism of injury (improper bending/calisthenics) and absence of red flag symptoms 3
    • No radicular symptoms reported (no radiation below knee, no neurological deficits) 3, 4
    • Duration <6 weeks suggests acute phase where conservative management is appropriate 3
    • Red flags absent: No bowel/bladder dysfunction, no progressive neurological deficits, no saddle anesthesia 3, 4
    • Important consideration: Depression and insomnia (though currently controlled) can amplify pain perception and complicate low back pain recovery 5, 6

Plan

Alpha-Stim Therapy

  • Continue current Alpha-Stim regimen given excellent therapeutic response for anxiety, depression, and insomnia 1, 2
  • Maintain daily use as prescribed (typically 60 minutes per day) 2
  • Continue monitoring for any delayed adverse effects, though none reported to date 2
  • Schedule routine follow-up in 3 months for ongoing reassessment 2

Acute Low Back Pain Management

Immediate Management (First 4 Weeks):

  • No imaging indicated at this time – routine radiography or advanced imaging (MRI/CT) is not recommended for nonspecific low back pain without red flags 3
  • NSAIDs: Initiate trial of NSAIDs for pain control 3, 7
  • Activity modification: Advise against complete bed rest; encourage return to normal activities as tolerated 3
  • Self-care education: Provide guidance on proper body mechanics, lifting techniques, and stretching exercises 3

Reassessment Strategy:

  • Schedule in-person or video visit in 2-4 weeks to perform comprehensive physical examination including:
    • Straight leg raise testing (sensitivity 91% for disc herniation) 4
    • Neurological examination (motor strength, reflexes, sensory testing) 3, 4, 7
    • Palpation and range of motion assessment 3
  • If symptoms persist beyond 4-6 weeks without improvement: Consider physical therapy referral and reassess for need for imaging 3, 7
  • Immediate imaging only warranted if: Severe or progressive neurological deficits develop, bowel/bladder dysfunction, or other red flag symptoms emerge 3, 4

Patient Education – Red Flags Requiring Urgent Evaluation:

  • Bowel or bladder dysfunction (urinary retention has 90% sensitivity for cauda equina syndrome) 4
  • Rapidly progressive weakness or foot drop 4
  • Saddle anesthesia 3, 4
  • Severe or worsening pain despite conservative measures 3

Psychosocial Considerations:

  • Monitor for pain-related mood changes: Given history of depression and anxiety, assess whether back pain impacts mental health at follow-up 5, 6
  • Emphasize continued Alpha-Stim use: Maintaining control of depression and insomnia is critical, as both conditions can worsen pain perception and delay recovery from low back pain 5, 6
  • The interplay between multisite pain and insomnia significantly increases risk of anxiety/depression recurrence (RR 2.42) 6

Follow-Up

  • 2-4 weeks: In-person or video visit for physical examination and reassessment of low back pain 3
  • 3 months: Routine Alpha-Stim therapy reassessment 2
  • Patient instructed to contact immediately if red flag symptoms develop 3, 4

References

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Sciatica and Foot Drop

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

7
Guideline

L4 Radiculopathy Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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