SOAP Note-Assessing Musculoskeletal System paper
SOAP Note-Assessing Musculoskeletal System paper
Subjective Data
Patient Particulars
Initials: D.K
Age: 42years
Gender: male
Ethnicity: American
Chief complaint: lower pain for one month
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? Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format SOAP Note-Assessing Musculoskeletal System paper
HPI: D.K is a 42 years old American male with complaints of lower back pain of gradual onset. The pain is sharp at the central position of the back (at the spine). It radiates to the left leg. The pain inductions are levered postures, prolonged sitting, and long-lever activities. The pain relievers are change of posture and constantly walking. The timing of the pain is at the onset of physical exertion and stops during the activity. Therefore, it does not interfere with the patient’s daily activities. The associated symptoms related to pain are numbness and muscle spasms. However, the patient denies fever, malaise, and weight loss. SOAP Note-Assessing Musculoskeletal System paper
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PMHX: has a positive history of left hip joint dislocation 10years ago after being involved in a road traffic accident.
FH: his mother has osteoarthritis and hypertension. His father has diabetes mellitus. His both grandparents have osteoarthritis
SH: positive for ETOH, has a 10pac year history of cigarette smoking. He is married and has two children. He works as a banker. He is obese and leads a sedentary lifestyle. SOAP Note-Assessing Musculoskeletal System paper
ROS
General: The patient denies fever, malaise, night sweats, and weight loss
Cardiovascular: the patient denies chest pain, swelling of extremities, dyspnea, syncope, and palpitations.
Pulmonary: the patient denies a cough, chest pain, breathlessness, sputum, and wheezing.
Gastrointestinal: the patient denies abdominal pain, nausea, vomiting, diarrhea, and constipation.
Objective data
Vitals: blood pressure is at 124/78mmHg, the pulse rate at 78beats per minute, the temperature at 36.4 degrees Celcius, SPO2 at 98%, height at 151 cm, and weight at 70kgs.
General: the patient is alert and oriented. He is well kempt and maintains eye contact. He has no pallor, jaundice, cyanosis, and edema.
Musculoskeletal: the patient assumes an upright gait and posture. There is no scoliosis or kyphosis noted. There is no swelling of the feet and the joints. There is no tenderness on palpation of the lumbar paraspinal and the buttocks. There are no superficial or deep muscle spasms. SOAP Note-Assessing Musculoskeletal System paper
Cardiovascular: the heart sounds S1and S2 are present at the 5th ICS MCL. The peripheral pulse is present and regular. There is no lower limb swelling.
Pulmonary: the chest has a symmetrical expansion, the lung fields are clear, and there is a resonant percussion note.
Abdominal: the abdomen is round, soft, and has no organ enlargement. The bowels are present. There is no fluid thrill and shifting dullness. SOAP Note-Assessing Musculoskeletal System paper
Diagnostic tests
The most appropriate imaging studies suggested for patients with lower back pain are; plain anterior-posterior and lateral lumbar spine radiograph, CT scanning, MRI, and myelography to check the bone, muscle, and nerve abnormalities. Laboratory tests recommended are urinalysis, stool analysis, and complete blood count to rule out infections. SOAP Note-Assessing Musculoskeletal System paper
Assessment
Differential diagnosis
Sciatica is the irritation or inflammation of the sciatic nerve due to herniated disk that causes pressure on the nerve root. Sciatica presents with lower back pain radiating to the entire leg. The pain is associated with muscle spasms, muscle weakness, and numbness (Jensen, et al, 2019). The risk factors for sciatica are the history of previous injury, overweight, sedentary lifestyle, and smoking. This is the most likely diagnosis because the patient has the risk factors and presents with similar symptoms.
Myelopathy is an injury of the spinal cord due to severe compression. The presenting signs and symptoms include lower back pain, decrease in fine motor skills, difficulties in walking, numbness, weakness, and difficulties in walking (Davies, et al, 2018). Causes of myelopathy are disc herniation, autoimmune diseases, spinal infections, and trauma. SOAP Note-Assessing Musculoskeletal System paper
Lumbar spondylosis is a condition characterized by new bone formation at the margins of the vertebral bodies (Kahn, et al, 2021). It is characterized by lower back pain radiating to the lower extremities associated with muscle weakness and numbness.
What nerve roots might be involved and how would you test for each one of them?
The nerve root involved in this patient is two nerves from the lumbar spine and three from the final section of the sacrum. These five nerve roots merge to form a long and straight sciatic nerve.
Physical examination performed
Physical examination involves assessing the gait and posture. Inspect the lower back for swelling and deformities such as kyphosis and scoliosis. Palpate the lower back for tenderness and disc dislocation.
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Special maneuvers performed
Common tests or maneuvers for sciatica that improve examination and efficiency are lumbar lateral bending, hip flexion, knee extension, and foot dorsiflexion. SOAP Note-Assessing Musculoskeletal System paper
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? Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format SOAP Note-Assessing Musculoskeletal System paper
