Below is the template you are to follow when developing your management plan. Also, always be sure to complete the EMR on the case. Use this template with each case. It is not a SOAP format as that is not required. Points will be deducted for not utilizing the template.
THIS SECTION IS 30 POINTS!!! Follow the bullet points below. Copy and answer each bullet point on a word document and cut and paste your responses to the management section!
Primary Diagnosis and ICD-10 code: Also include any procedural codes.
3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
Additional laboratory and diagnostic tests: It may be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.
Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending it to the hospital, what orders would you write for a direct admit?
Therapeutic modalities: pharmacological and nonpharmacological management.
Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
Patient education: Explanations and advice given to patient and family members.
Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
References (minimum of 3, timely, that prove this plan follows the current standard of care).
Case study
A 2-year-old female presented to the clinic setting today accompanied by her mother who states
the patient is experiencing cough, runny nose, and fever. She is an otherwise healthy toddler who
is appropriately reaching milestones.
Subjective:
Chief complaint:
Cough, runny nose, and fever
History of present illness:
Emma is a 2-year-old, African American female presenting to the clinic today with her
mother who is complaining of the patient having symptoms of cough and runny nose for two
days and fever of 101 since yesterday. Emma’s mother denies sputum when she coughs, denies
hemoptysis, and denies tugging on her ears. She has received all vaccinations except for her
influenza vaccine. Emma has not received any OTC medications since her symptoms began. She
has had a decreased appetite but is still drinking liquids well. She has had several wet diapers and
has had normal stools. She woke up several times throughout the night with fussiness and crying.
Her mother states Emma has been exposed to sick children at the daycare and is exposed to
second-hand smoke in the home daily by both parents.
Past medical history:
Illness/ hospitalizations/ surgeries.
States generally in good health. No history of
hospitalizations. Normal full-term vaginal delivery. Breast-fed until 1 month of age and was then
provided formula.
Medications:
None
Allergies:
no known allergies
Preventative Health:
She has met all developmental milestones for her age. She has had
regular well checks.
Social history:
She lives in an apartment with her mother, father, and 5-year-old brother. Both
parents smoke in the home. They own one dog, a chihuahua that lives in the home. Her father is
a customer service representative, and her mother is an office manager. Both her paternal and
maternal grandparents live by for support.
Family history:
Father: 35 years old, mild intermittent asthma, uses albuterol as need, smoker
Mother: 31 years old, smoker
Brother: 5 years old, health
