SOAP (custom)

Consent: Verbal consent obtained for assessment and treatment. Acupuncture checklist: Not applicable. Diagnosis: Lumbar radiculopathy. Subjective: - Patient presents today with lower back pain radiating into the left leg. - The pain started three weeks ago, is constant, and is located in the lower back and left leg. The pain is described as a sharp, shooting pain, rated as 7/10 in severity. It is worse with prolonged sitting and standing, and improves with rest and lying down. - The patient reports that over-the-counter pain relievers provide minimal relief. Heat packs offer some comfort. - The symptoms have gradually worsened over the past three weeks. - No previous episodes of similar symptoms. - The pain is significantly impacting the patient's ability to work and participate in recreational activities. - Associated symptoms include numbness and tingling in the left foot. Past Medical History: - No significant past medical history. - The patient is a non-smoker and drinks alcohol occasionally. - No family history of back pain or neurological conditions. - No known exposures. - Immunization status up to date. - Other: Patient denies any recent injuries or falls. Objective: - Vitals signs: Not assessed. - Physical or mental state examination findings, including system specific examination(s): Lumbar spine examination revealed reduced range of motion in flexion and lateral flexion. Positive straight leg raise test at 45 degrees on the left. Neurological examination showed decreased sensation in the L5 dermatome and reduced reflexes at the left ankle. - Investigations with results: Not applicable. Assessment: - Likely diagnosis: Lumbar radiculopathy. - Differential diagnosis: Lumbar sprain/strain, disc herniation. Plan: - Investigations planned: MRI lumbar spine. - Treatment planned: Physiotherapy including manual therapy, exercises for core strengthening and flexibility, and education on posture and body mechanics. Recommend a course of 6 sessions. - Relevant other actions such as counselling, referrals etc: Advised patient to avoid activities that exacerbate symptoms. Referred to GP for consideration of medication for pain management.