Soap Note Name, Date 11/3/2017, Time 10:33, Age 33, Female,

SOAP NOTENAMEDBDATE1132017TIME 1033AMAGE33SEXFEMALESUBJECTIVEc

Analyze the detailed patient encounter and medical management scenario, including subjective complaints, physical findings, diagnosis, and treatment plan, with both clinical reasoning and evidence-based references.

Paper For Above instruction

The patient presented with acute lower back pain characterized by a burning sensation that intensified after a day of prolonged standing at her job as a cashier. Utilizing the OLDCART method, the pain's onset was recent, specifically starting yesterday during work, with persistent stiffness and discomfort that worsened with movement, bending, or lifting. The pain radiated to her right buttock, typical of lumbar strain, and did not resolve with over-the-counter analgesics, notably Tylenol. Her history revealed no prior episodes of back pain or trauma, which reduces suspicion for chronic degenerative issues but highlights acute muscular strain probably exacerbated by her occupational demands.

The physical examination showed sign of muscle spasm in the right paravertebral lumbar area, limited by pain during range of motion, but no neurological deficits such as weakness, paresthesias, or reflex changes. The straight leg raise test was negative, ruling out true sciatica or herniated disc as immediate diagnoses. Vital signs were within normal limits, and no systemic signs of infection or inflammation were noted. Skin inspection was normal aside from dryness, and other systems like cardiovascular, respiratory, and gastrointestinal examinations revealed no abnormalities that would suggest secondary causes of her back pain or other underlying conditions.

The differential diagnoses considered included acute lumbar strain (ICD-10 M54.5) as the primary diagnosis, supported by the muscle spasm and absence of neurological deficits. Other considerations were herniated disc (M51.2) and sciatica (M54.3), but these were less likely given the physical exam findings. The combination of her occupational history, recent increase in standing hours, and absence of prior trauma pointed toward muscular strain secondary to overuse.

The treatment plan focused on symptomatic relief and functional restoration. Pharmacological management was initiated with NSAIDs—ibuprofen 600 mg every eight hours for seven days—due to better anti-inflammatory effects, complemented by muscle relaxants such as Robaxin (methocarbamol) 500 mg twice daily for two weeks. She was advised on non-pharmacological measures such as applying ice initially, then heat, and modifying her activity to avoid further strain; complete bed rest was avoided to prevent deconditioning. She was instructed in proper lifting techniques, postural adjustments, and activity modifications to prevent recurrence.

Further patient education emphasized ergonomic principles: avoiding jerky movements, lifting with legs, keeping objects close, and using supports or repositioning to reduce lumbar stress. Return to work was recommended within 4-8 days, with a gradual resumption of activities, and recommencement of aerobic exercises like walking or swimming after symptom improvement. Follow-up was scheduled in 7-10 days to assess progress, with instructions to revisit sooner if neurological symptoms or new deficits develop. No additional diagnostic tests such as MRI were deemed necessary initially, given the clinical picture and safety of conservative management.

Evidence-based guidelines, such as those from the American College of Physicians and the American Academy of Family Physicians, endorse conservative treatment for acute low back pain, emphasizing NSAIDs, activity modification, and patient education (Chou et al., 2017). This approach aims to reduce misuse of imaging and invasive procedures, supporting recovery and return to function (Qaseem et al., 2017). The importance of ergonomic education and activity modification in preventing recurrence aligns with current best practices in musculoskeletal management.

In conclusion, this case underscores the value of a thorough history and physical exam in distinguishing muscular strain from other serious pathologies. Employing evidence-based management strategies optimizes recovery, minimizes unnecessary interventions, and emphasizes patient-centered education for sustainable health outcomes (Deyo et al., 2014). Continuous follow-up and monitoring are critical to ensure resolution and prevent future episodes, considering her occupational risk factors and personal circumstances.

References

  • Chou, R., Deyo, R., Friedly, J., et al. (2017). Noninvasive treatments for low back pain. Annals of Internal Medicine, 166(7), 514-530.
  • Deyo, R., Mirza, S. K., & Turner, J. A. (2014). Preliminary estimates of reductions in spinal fusion procedures for degenerative disc disease in the United States. Spine, 39(15), 1247-1252.
  • Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514-530.
  • Bickley, L. S. (2007). Bates’ Guide to Physical Examination & History Taking (9th ed.). Lippincott Williams & Wilkins.
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