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Asked by PresidentJackal1616

1. Julie is a 26-year-old hockey coach who was violently hit into the end boards about two weeks ago and was removed from the ice on a stretcher. Her head CT was clear and neck X-rays were negative. She presents today for 8 out of 10 lower back pain that is not responsive to Motrin. She has no radicular symptoms and no other past medical history.

 

Answering in 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

 

SCIENCE
HEALTH SCIENCE
NURSING
NURS 6501

 

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