Make A SOAP Note, Not A Narrative Essay Assessing Musculoske

Make A Soap Note Not A Narrative Essayassessingmuscoskeletaldiscussio

Make A Soap Note Not A Narrative Essayassessingmuscoskeletaldiscussio Make A Soap Note Not A Narrative Essayassessingmuscoskeletaldiscussio Make a SOAP Note Not a narrative essay: Assessing Muscoskeletal Discussion: Assessing Muscoskeletal Pain The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provide the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging.

Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams. In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance.

Remember that not all comprehensive SOAP data are included in every patient case. Case 1: Back Pain A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them?

What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Paper For Above instruction

Subjective:

The patient is a 42-year-old male presenting with a one-month history of lower back pain. He reports intermittent pain that radiates to his left leg. The pain is described as aching and is worsened with prolonged activity. No history of trauma, recent infections, or surgical interventions. No prior episodes of similar pain. The patient denies bowel or bladder incontinence, numbness, or weakness although these symptoms should be actively inquired about given the radicular nature of his pain.

Objective:

• Vital signs: Stable, within normal limits
• Inspection: No visible swelling, deformities, or skin changes over the lower back
• Palpation: Tenderness over lumbar vertebrae and paraspinal muscles
• Range of motion: Limited due to pain, especially in forward flexion
• Neurological Testing:
  • Sensation: Intact to light touch in lower extremities, but with some decreased sensation along the lateral and dorsal aspects of the left leg
  • Motor strength: Slight weakness (4/5) in dorsiflexion of the left foot
  • Reflexes: Normal reflexes in both knees and ankles, no asymmetry

Assessment:

The patient's presentation suggests radiculopathy, most likely involving nerve roots that contribute to the sciatic nerve (L4-S3). The radiating pain and neurological symptoms point to possible nerve compression often caused by lumbar disc herniation or degenerative disc disease. Differential diagnoses include lumbar strain, facet joint syndrome, spinal stenosis, and less commonly, neoplasm or infection. The absence of systemic symptoms and trauma makes inflammatory or infectious causes less likely but remains to be ruled out.

Plan:

• Further diagnostic imaging: Lumbar MRI to visualize disc pathology and nerve root compression
• Laboratory tests: ESR, CRP if infection or inflammatory process suspected
• Physical examination:
  • Straight leg raise test: Positive on the left at around 30 degrees, supporting disc herniation
  • Crossed straight leg raising: To check for nerve root impingement
• Patient education: Advice on activity modification, NSAIDs for pain relief, and ergonomic advice
• Follow-up: Reassess after imaging results; consider referral to orthopedic specialist if necessary

References

• Deyo, R. A., & Mirza, S. K. (2016). The science of low back pain. The New England Journal of Medicine, 374(17), 1643–1650.
• Frymoyer, J. W. (1988). Back pain and sciatica. The New England Journal of Medicine, 318(5), 291–300.
• Herniated disc. (2023). In UpToDate. Retrieved from https://www.uptodate.com
• Lurie, J. C., et al. (2014). The specificity of physical examination tests in patients with suspected lumbar disc herniation. Spine Journal, 14(9), 1918–1929.
• Mansfield, S. J., et al. (2010). Physical examination tests for diagnosing nerve root impingement: A systematic review. Musculoskeletal Science and Practice, 15(2), 74–80.
• Mehnert, F., et al. (2018). Spinal stenosis: Evaluation and management. American Family Physician, 97(12), 776–783.
• NICE guidelines. (2019). Low back pain and sciatica in over 16s: assessment and management. National Institute for Health and Care Excellence. Retrieved from https://www.nice.org.uk
• Roland, M., & Morris, R. (1983). A study of the natural history of low-back pain. British Medical Journal, 288(6400), 1424–1426.
• Singh, S. P., et al. (2019). Imaging in the diagnosis of lumbar disc herniation. Journal of Orthopaedics and Rheumatology, 2(3), 333–340.
• Williams, C. M., et al. (2017). The role of physical examination in diagnosis of lumbar radiculopathy. Journal of Manual & Manipulative Therapy, 25(4), 242–249.