W5 Discussion Question

Follow template. easy less words just fill it

Case Study Chosen: Linda is a 45-year-old female who returns to the office four weeks
after a slip and fall at home. Initially, she had some mild-to-moderate soreness that was
alleviated with heat and occasional Aleve. She now presents with pain across her lower
back, pain with sitting and standing, and radiation of pain and numbness through her right
buttock and down through her right thigh. She is taking Aleve twice daily and Tylenol
every eight hours with moderate relief of pain, but it doesn’t help with the numbness. The
pain wakes her at night. There has been no change in her bladder or bowel habits.
Demographics: Age/Gender
SUBJECTIVE
● CC:
● HPI: (As listed from Case Study Information)
● Subjective: (What questions will you ask? Must be listed by System, ONLY as
it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to
toe unless pertinent).
OBJECTIVE
General:
● VS BP, HR, RR, Weight, Height, BMI
● Physical Exam Elements: (Must be listed by System, ONLY as it pertains to
Chief Complaint/HPI. Should NOT be all systems or full head to toe unless
pertinent.)
● POC Testing (any Point of Care (POC) testing specifically performed in the
office): What tests (if any) did you perform during the visit (urine dip, rapid
strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.
ASSESSMENT
● Working Diagnosis: (Must include ICD 10)
● Differential Diagnosis:
PLAN
● Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if
you will be ordering for your patient. Remember the importance of appropriate
resource utilization. Remember you are managing this patient in the CLINIC
setting, NOT THE HOSPITAL.
● Treatment: Must include full Sig/Order for all prescriptions and OTC meds
(Name of medication, dosage, frequency, duration, number of tabs, number of
refills). CANNOT only list drug class. Should follow evidence-based guidelines.
● Referrals: If Applicable
● Education:
● Health maintenance:
● RTC:
Table 1. Common Musculoskeletal Diagnoses. In addition to your SOAP note, you must
also complete the following table. Upload your SOAP note and table to the discussion
board.
Diagnosis
Low back
pain/lumbago
Cauda Equina
Syndrome
Plantar Fasciitis
Degenerative Joint
Disease
(Osteoarthritis)
Signs/Symptoms
Gold Standard
Gold Standard
Diagnostics
Treatment
Ankylosing
Spondylitis
Meniscus Tear
Hip Fracture
Pelvic Fracture
Navicular Fracture
Colles Fracture
Ankle Sprain
**Clinical Pearl**
Type of Scan
Indication
X-ray
Bone fractures/damage, OA,
metal, dense objects
Special Considerations
MRI
Gold standard for injuries to
No metal, pacemakers,
cartilage, meniscus, tendons
aneurysm clips
and ligaments
CT
Views structures like masses,
trauma, fractures, bleeding.
Forms 3-D picture
More cost effective than MRI