No need for cover page or page numbers. thank you
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including the inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
QUESTION: Matthew is a 52-year-old truck driver who is seeing you today for his physical. He states that he has been in his usual state of health, but missed his physical for the past few years. His BP is 165/90, HR 90, Height 6’2, Weight 204. Total Cholesterol 244, HDL 32 LDL 166 Triglycerides 344 A1C 6.8.
Template example
SOAP FORMAT
SUBJECTIVE:
Questions you will ask….Ask the patient questions!!!
HPI
PMHx
FHx
SHx
Medications
ROS
OBJECTIVE:
Vitals with BMI
Constitutional
HEENT
Cardiac
Pulmo
GI
Musculoskeletal
Skin
GU – if relevant
Always provide a very detailed physical exam, or descriiption of what you want to elicit on your physical exam on the organ system involved in your chief complaint
ASSESSMENT:
Working Diagnosis
– provide ICD 10 codes
– provide rationales or pertinent positives and negatives that made you consider the diagnosis
Differential # 1
– diagnosis you cannot miss.
– rationale why it can’t be missed
– provide ICD 10 code
Differential # 2
– what else could it be?
– rationale why you ruled it out
-provide ICD 10 Code
PLAN
Diagnostics
Pharmacological Plan – indicate dosage and regimen, if not indicated state accordingly
Health Education Plan
Referral Plan – if not indicated, state accordingly
Follow-up plan – indicate when patient needs to follow-up and what symptoms to watch out for
Health promotion plan – age-specific health promotion recommendations not related to the case per USPTF
National Standards of Care/ Short Narrative for working diagnosis
REFERENCES- Scholarly sources please
