SOAP (Neuro)

**Subjective:** - Patient presents with complaints of lower back pain and radiating pain down the left leg. - Pain started 2 weeks ago, constant ache with sharp, shooting pains. Located in the lumbar region, radiating down the posterior aspect of the left leg to the foot. - Pain is worsened by prolonged sitting and bending. Relieved by lying down and using a lumbar support. - Symptoms have gradually worsened over the past two weeks. - No previous episodes of similar pain. - Pain limits ability to sit for more than 30 minutes, affecting work and leisure activities. - Associated symptoms include tingling and numbness in the left foot. **Past Medical History:** - Patient reports no significant past medical or surgical history. - Patient is a non-smoker and drinks alcohol occasionally. Works as a desk-based office worker. - Family history of back pain in father. - No known exposure history. - Immunization status up to date. - No other relevant subjective information. **Objective:** - Vitals: BP 130/80, HR 78, RR 16, SpO2 98%. - Physical examination reveals limited lumbar flexion and extension. Positive straight leg raise test on the left at 45 degrees. Reduced sensation in the L5 dermatome. - No investigations with results. **Treatment: ** - Patient performed lumbar stabilization exercises. - Treatment modalities used: Manual therapy to the lumbar spine and soft tissue mobilization. - Patient educated on proper posture and body mechanics. Advised to avoid prolonged sitting. **Assessment:** - Likely diagnosis: Lumbar radiculopathy secondary to disc herniation. - Differential diagnosis: Spinal stenosis, facet joint syndrome. - Analysis of movement patterns: Restricted lumbar range of motion, altered gait pattern. **Plan:** - Investigations planned: MRI lumbar spine. - Treatment planned: Continue with manual therapy, exercises, and education. - Referral to pain management clinic.