A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg

  • Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. . Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
  • Please POST a SOAP Episodic/FOCUS note ONLY!
  • Refer to the Episodic/Focused SOAP Template in the Week 8 Learning Resources. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
  • PLEASE READ – HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient.
  • Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
    Location: head
    Onset: 3 days ago
    Character: pounding, pressure around the eyes and temples
    Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
    Timing: after being on the computer all day at work
    Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
    Severity: 7/10 pain scale
  • Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see.
  • Always document in head to toe format i.e. General: Head: EENT: etc
  • For the Physical exam section, you are to exam systems related to the CC. I am getting a paragraph for this area and this is INCORRECT. Please examine the systems that should be associated with the Musculoskeletal complaint. Systems NOT associated with CC will receive a Strick through (HEENT) in my comments when grading your assignment. Please examine the systems below.
  • General:
  • Chest/Lungs:.
  • Heart/Peripheral Vascular:
  • Musculoskeletal:
  • Lymphatics:
  • Psychiatric

PLEASE POST YOUR SOAP NOTE SO THAT IT CAN BE SEEN.

DO NOT use an attachment.

The template is in the Resource List, Please use it and do NOT make up your own.

You also need to mention the maneuvers you would use with your assigned 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

  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • Consider what history would be necessary to collect from the patient in the case study you were assigned.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. These should be MUSK diagnoses.

Requirements: na

Nursing

Answer preview for the paper on ‘A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg’

lower back for the past month

APA 1240 words

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