Diagnosis | Signs/Symptoms | Gold Standard Diagnostics | Gold Standard Treatment |
Low back pain/lumbago | Low back pain May radiate down to one or both legs | Physical assessment and history x-ray, MRI or CT scan | Avoid lifting heavy objects Acupuncture, message, mobilization or manipulation of the spine, osteopathy, shoe inserts, ultrasound and laser treatments, as well as transcutaneous electrical nerve stimulation (TENS) |
Cauda Equina Syndrome | |||
Plantar Fasciitis | |||
Degenerative Joint Disease (Osteoarthritis) | |||
Ankylosing Spondylitis | |||
Meniscus Tear | |||
Hip Fracture | |||
Pelvic Fracture | |||
Navicular Fracture | |||
Colles Fracture | |||
Ankle Sprain | Anterior drawer test Varus stress test Ottawa Ankle Rules | Stabilization 2-3 days of rest and elevation PRICE therapy |
Instructions: SOAP format is the documentation style you will be using in your clinicals; this also adheres to the thought processes involved in formulating the correct diagnosis and treatment plan. You will present the subjective data first, including all questions that you want to ask. Next is the gathering of objective data that supports your subjective data; if there is none given, then you will determine by system what kind of physical exam elements you want to elicit. After this, you are ready to provide differentials and a working diagnosis based on the above data. After arriving at the appropriate working diagnosis, you will then formulate a treatment plan. Please be sure to follow the template below for your initial discussion board postings. Postings should be concise and
NOT in narrative format.
Use evidence based practice
Case Study Chosen:
1. 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:
