How to Answer Write Assessment Portion Questions (Complete Guide)

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What This Question Is About

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How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

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Original Question

Write the Assessment portion of the SOAP note. Chief Complaint (CC): A 48-year-old male presents to the primary care clinic with complaints of intermittent lower back pain and numbness in his right leg for the past 3 weeks. History of Present Illness (HPI): The patient reports that the pain began after lifting a heavy box at work. The pain is described as a dull ache in the lower back, occasionally radiating down the right posterior thigh and into the calf. He rates the pain as 6/10 at its worst and 2/10 at rest. He notes occasional numbness and tingling in the right foot, especially after prolonged standing. He denies bowel or bladder incontinence, fever, or recent trauma. He has felt more irritable and anxious since the pain started, with some difficulty sleeping. Past Medical History (PMH): Hypertension, Mild depression (diagnosed 2 years ago) Medications: Lisinopril 10 mg daily, Sertraline 50 mg daily, Occasional ibuprofen Social History (SH): Works as a warehouse supervisor, Smokes 1 pack per day, Drinks alcohol socially, Lives with spouse, supportive home environment. Physical Examination: Patient appears mildly distressed due to pain but is alert and oriented. Gait: Slight limp on right side. Lumbar ROM: Flexion limited by pain, extension normal. Palpation: Tenderness over lower lumbar paraspinals, no swelling. Neurological: Decreased sensation to light touch on right lateral calf and foot; 4/5 strength in right dorsiflexion; positive straight leg raise on right at

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