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Asked by liliyabee

Linda is a 45-year-old female who returns to the office four weeks after a slip and fall at home. Initially, she had some mild-to-moderate soreness that was alleviated with heat and occasional Aleve. She now presents with pain across her lower back, pain with sitting and standing, and radiation of pain and numbness through her right buttock and down through her right thigh. She is taking Aleve twice daily and Tylenol every eight hours with moderate relief of pain, but it doesn’t help with the numbness. The pain wakes her at night. There has been no change in her bladder or bowel habits.

 

Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including the inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care. Needs to be done in SOAP  format 

 

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 663LA

 

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