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Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
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.
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