i need help writing a soap chart for a client who is having lower back pain on right side?
i have to create a soap chart for a client who is having lower back pain on her right side. also i have to use seven muscles that is causing her pain and it has to be a maximum of 3 pages,and add a 60 minute treatment plan.
Public Comments
1. If this is client who needs the help and you don't know what you are doing, I'd strongly advise you to get your superiors help in this. When it comes to a persons health issues, you cannot make any mistakes and doesn't seem like you are sure of what you are doing. No shame in not knowing what you are doing but for a partients medical care you cannot turn Yahoo for the answers you are suppose to be a professional based on your saying this is your client.This is a persons health, you speak with the patients Dr. You need to make sure you do the right thing and doesn't sound like you know what you are doing. I mean no harm in my statement but I wouldn'r want someone working on me who hadn't a clue what they were doing.
2. Prior to any myofascial treatment plan you're going to want to understand and be able to defend your actions. That said, a list of involved musculature will involve a slightly more comprehensive "subjective" complaint history. For example, what sort of actions lead to increased pain vs. what actions lead to less or no pain. Seek to become a good detective as well as a good mime. Duplicate these actions as though you're experiencing them in your own body. In order to properly diagnose their issues you'll want to recall specific musculature responsible for these actions. If this answer sounds too unspecified, remember that your greatest call is to become a good diagnostician - this may mean becoming a good puppeteer rather than to regurgitate muscle names. If you reduce this process to merely recalling a specific number of muscles you may miss an opportunity to provide good care. Could be Quadratus Lomborum resulting from contraction of Illio/Psoas due to numerous types of actions - too many to list. Muscular splinting could involve a suite of other myofascial maladies, not the least of which can include all musculature related to and attached to the Thoraco Lumbar Aponeurosis (TLA).
3. Tell your patient to go to a chiropractor. Problem solved.
4. S: Ask her what the pain feels like. What makes it better. What makes it worse. Ask her to rate it on a 0-10 scale with 10 being the worst pain imaginable and 0 being no pain at all.
O: Document whether she is grimacing or guarding, Describe how she appears. Is she smiling, frowning, clutching her right side. Whats going on with her.
A; Document her vitals, level of comfort- or pain assessment is it a 3 or a 10 on a 0-10 scale and how does she react following administration of pain meds. Do a physical assessment of those 7 muscles. ( who says the pain is musculoskelatal) Evaluate the color of her urine. Strain her urine. . Is she on her period. What kind of a job does she have. Does she carry a child. Is she carrying a book bag. Does she have back strain. Does anything make the pain better. Has she had this pain before. Has she been diagnosed with a disease which may cause the pain. Does she notice anything unusual about the way her position improves the pain. on and on and on
P: What do you plan to do for the pain. ice, heat, pain pills, pain clinic....urology consult, strain urine for stones. Ibuprophen, Naproxen, etc......on and on and on................
