Watch The Following Videos Then Complete The Required Assign

Watch The Following Videos Then Complete the Required Assignment Rev

Review the document in Course Resources for instructions on accessing the videos. Lab 1 OSCE Clinical Skills Back pain 23:59 Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan? Lab 2 OSCE Clinical Skills Shoulder pain 24:30 Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan? How to Submit Submit your SOAP notes to the unit Dropbox before midnight on the last day of the unit. Please submit your Lab directly into the text submission tool located in the Unit Lab Dropbox.

Paper For Above instruction

Introduction

Effective clinical documentation is essential for providing high-quality patient care and ensuring clear communication among healthcare providers. The SOAP (Subjective, Objective, Assessment, Plan) format is a widely used method for structuring clinical notes. This paper presents SOAP notes for two clinical scenarios based on viewing instructional videos: one involving a patient with back pain and another with shoulder pain. Additionally, the paper reflects on potential modifications to the initial plans based on the scenarios.

Case 1: Back Pain

Subjective: The patient reports experiencing persistent lower back pain for the past two weeks. The pain is described as dull and aching, with intermittent sharp sensations. The pain worsens after prolonged sitting or physical activity and is somewhat relieved by rest. The patient denies radiation of pain down the legs, numbness, or weakness. No recent trauma or injury is reported. The patient’s medical history includes hypertension and a sedentary lifestyle.

Objective: Vital signs are within normal limits: BP 128/80 mm Hg, HR 72 bpm, RR 16/min, Temperature 98.6°F. The back shows no visible deformity or swelling. Palpation reveals tenderness in the lumbar paraspinal muscles. Range of motion is slightly limited due to pain, especially during forward flexion and extension. No neurological deficits are evident: reflexes are normal, and there is no loss of sensation or muscle strength in the lower limbs.

Assessment: The presentation suggests mechanical lower back pain likely due to muscular strain or ligamentous sprain, given the absence of neurological deficits and trauma. Differential diagnoses include herniated disc, degenerative disc disease, or facet joint syndrome, but clinical signs do not currently point to these.

Plan:

- Advise the patient to rest and avoid activities that exacerbate pain.

- Prescribe NSAIDs for pain relief and inflammation reduction.

- Recommend gentle stretching and physical therapy.

- Educate on proper ergonomics and posture.

- Follow-up in two weeks if symptoms persist or worsen.

- Consider imaging if neurological symptoms develop.

Reflection: If I were managing this patient, I might include more detailed questions about daily activities and ergonomic habits. I would also consider early referral for physical therapy and education on body mechanics to prevent future episodes.

Case 2: Shoulder Pain

Subjective: The patient complains of persistent right shoulder pain for three weeks, described as a deep ache worsened by overhead activities and movement. The pain limits the patient’s ability to perform daily tasks and sleep. There is no history of trauma. The patient reports preceding episodes of discomfort after repetitive overhead work or sports.

Objective: Inspection reveals slight swelling and tenderness localized over the rotator cuff. Range of motion is reduced, particularly in overhead elevation and external rotation. Strength testing shows weakness in abduction and external rotation. No neurovascular deficits are identified. Special tests such as impingement signs are positive.

Assessment: The findings are consistent with rotator cuff tendinopathy or impingement syndrome. Differential diagnoses include rotator cuff tear or shoulder bursitis.

Plan:

- Rest and activity modification.

- NSAIDs and ice application.

- Initiate physical therapy focusing on rotator cuff strengthening.

- Consider imaging, such as MRI, if no improvement in 4-6 weeks.

- Educate the patient about joint protection and ergonomic strategies.

Reflection: I would consider early referral to an orthopedic specialist if symptoms persist beyond initial conservative management. Additionally, I might include corticosteroid injections for symptomatic relief in refractory cases.

Conclusion

The healthcare process relies heavily on accurate and organized documentation. The SOAP format effectively captures patient history, findings, and management plans. Reviewing these scenarios increases awareness of clinical reasoning and highlights areas for potential improvement, such as early intervention and patient education strategies.

References

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