Miami Dade College Lower Back Pain Episodic Focused SOAP Note

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?

With regard to the case study you were assigned:

• 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.

By Day 3 of Week 8

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.