solved

A 54-year-old male presents with pain in both feet, with swelling to his right big toe. He has a temperature of 100 and also complains of hand pain. The patient states that he has had pain in his feet before. His wife usually gives him ginger tea, which goes away in a day or two, but it hasn’t helped. Your assessment demonstrates a tender and swollen right first MTP with redness and pain throughout the midfoot. There is also pain in the left midfoot. The patient also has a history of essential hypertension and takes HCTZ 25mg daily.
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.

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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