solved

Mrs. J., age 42, has been married for 20 years to a high school teacher. She has 16-year-old twins who are in high school. She is coming in for a routine physical, because she said over the phone that she has no energy and has lost some weight. She also thinks she has had a temperature for several days. She has the following physical exam findings: temperature, 101°F; weight loss of 10 lbs. since her previous visit last year; flu-like symptoms; nonproductive cough; bilateral lymphadenopathy in cervical and supraclavicular nodes; and decreased breath sounds in bilateral bases.
In below format, please answer
SOAP FORMAT
SUBJECTIVE:
Questions you will ask
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 description 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

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