solved

Jenny G., a 48-year-old recovering intravenous (IV) drug abuser, presents with general malaise, anorexia, abdominal pain, and slight jaundice. She is currently staying in a women’s shelter and is looking for a job. She is divorced with two grown children whom she hasn’t been in contact with for years. She returns to your office for her lab results. You note that her ALT is elevated, and her Hepatitis A and C antibodies are positive.
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
REFERENCES last 5 years

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