The link below is the overview of the SOAP note assignment:(abdominal assessment. SOAP note sample essay)

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It can be on cardiac/peripheral vascular OR abdominal assessment.

Solution

abdominal assessment. SOAP note sample essay

CASE 1

Muscle strain causes radiating pain only in the affected area. Muscle strain also causes muscle spasms, cramping, swelling, and discoloration (Poor et al., 2018). However, in this case, the patient experiences pain from the lower back pain towards the left leg. Besides, there is no swelling, spasms, cramping, or discoloration of the affected symptomized muscle strain injuries.(abdominal assessment. SOAP note sample essay)

The most appropriate diagnosis, in this case, is Sciatica. Sciatica is a form of pain that emanates from the lower back down the hips, thighs, and legs along the nerve root path. Sciatica condition typically affects one side of the body at any given time (Foster et al., 2017). In this case, the patient’s pain originates from the lower back towards the left leg, as symptomized by a sciatic condition. Therefore, this diagnosis is has considered all the facets of the patient’s symptoms.(abdominal assessment. SOAP note sample essay)

This diagnosis is also supported by the patient’s subjective and objective data on obesity, diabetes, and occupation (Davis & Vasudevan, 2018). For instance, overweigh or obesity can cause changes of the spinal cord leading to the development of sciatica by increasing tension on the spine. The patient, in this case, is an active person, working as a cable technician and also plays soccer. Diabetes alters the way the body system absorbs sugar and raises the risk of neurological degradation. Besides, physical activity increases the incidence of Sciatia conditions since it is associated with repeated trauma on the spinal cord. According to Davis & Vasudevan (2018), drivers of long haul trucks, industrial operators, and occupations that require employees to be in physically uncomfortable positions have all been linked to sciatic and the subsiquent  lower back pain (Davis & Vasudevan, 2018).(abdominal assessment. SOAP note sample essay)

References

Davis, D., & Vasudevan, A. (2018). Sciatica. StatPearls [Internet]

Foster, N. E., Konstantinou, K., Lewis, M., Ogollah, R., Dunn, K. M., van der Windt, D., … & Hay, E. M. (2017). The clinical and cost-effectiveness of stratified care for patients with Sciatica: the SCOPiC randomized controlled trial protocol (ISRCTN75449581). BMC musculoskeletal disorders, 18(1), 1-15. https://doi.org/10.1186/s12891-017-1513-5

Poor, A. E., Roedl, J. B., Zoga, A. C., & Meyers, W. C. (2018). Core muscle injuries in athletes. Current sports medicine reports, 17(2), 54-58. https://doi.10.1249/JSR.0000000000000453

CASE 2

Muscle pain often has localized pain in the affected area (Poor et al., 2018). Besides, muscle train is associated with a sudden onset of pain, soreness, swelling, and muscle spasms of the affected muscle. Depending on the type of muscle strain, the symptoms include pain in contraction or stretching, mild edema, hemorrhage, and loss of function (Poor et al., 2018). In this case, the patient does not experience soreness, swelling, or muscle spasm save for a sharp pain, which sometimes radiates to the left leg and exacerbates with activity.(abdominal assessment. SOAP note sample essay)

The likely condition for this case’s diagnosis is the degenerative lumbar spondylolisthesis. Degenerative lumbar spondylolisthesis is characterized by intermittent and localized lower back pain. The pain can also be radicular in instances when the nerve roots are compressed, improving in some positions and exacerbating in others. The patient in this case study experiences radicular pain the ease without activity. According to Zhang et al. (2019), degenerative lumbar spondylolisthesis is predominated with radicular symptoms, with or without positional variance.(abdominal assessment. SOAP note sample essay)

Furthermore, the patients’ medical history of hypertension, diabetes, and high blood pressure. diabetes and associated comorbidities are said to cause chronic back pain and have poorer patient-reported results than those without such conditions (Nagata et al., 2021). Therefore, this diagnosis is the most accurate since it is supported by the most clinical information obtained for this case.(abdominal assessment. SOAP note sample essay)

References

Nagata, K., Nakamoto, H., Sumitani, M., Kato, S., Yoshida, Y., Kawamura, N., … & Oshima, Y. (2021). Diabetes is associated with greater leg pain and worse patient-reported outcomes at 1 year after lumbar spine surgery. Scientific Reports, 11(1), 1-8. https://doi.org/10.1038/s41598-021-87615-y

Poor, A. E., Roedl, J. B., Zoga, A. C., & Meyers, W. C. (2018). Core muscle injuries in athletes. Current sports medicine reports, 17(2), 54-58. https://doi.10.1249/JSR.0000000000000453

Zhang, D., Zhang, W., Zhou, X., & Jin, S. (2021). Comparison of CLIF and TLIF in treatment of degenerative lumbar spondylolisthesis combined with lumbar spinal stenosis. Zhongguo xiu fu Chong Jian wai ke za zhi= Zhongguo Xiufu Chongjian Waike Zazhi= Chinese Journal of Reparative and Reconstructive Surgery, 35(2), 210-216. https://doi.10.7507/1002-1892.202008092