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SCENARIO: A 38-year old male construction worker complains of severe pain to his right lower back. States he woke up with the pain after an especially difficult work day.
Discuss:
1. what questions you would ask the patient
2. what physical exam elements you would include
3. what further testing you would want to have performed.
In SOAP (SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN) format (SEE UPLOADED TEMPLATE), list:
-Pertinent positive and negative information
-Differential and working diagnosis (WORKING DIAGNOSIS IS ACUTE LOW BACK PAIN)
-Treatment plan (FIRST LINE TREATMENT), including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
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