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A 27 year- old male is seen in the student health clinic for a complaint of harsh cough for 3 days. He stated he is tired, woke up sweaty and has no energy. His vital signs are taken by the medical assistant and are 100.8-92-26, 138/82. Upon exam he is found slightly short of breath, with cervical lymphadenopathy, yellow sputum, bilateral rales in lower bases.
Develop a list of differential diagnoses using a SOAP format.
Subjective data (S)- what he states
Objective data (O)- what is observed through exam
What is your conclusion of possible medical diagnoses for this patient?
Assessment (A)- List your differential diagnoses
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Plan(P): What meds, lab/diagnostic tests, treatments, consults would you prescribe?
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