The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part.
The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan.
The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.
The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagno
Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives: SUBJECTIVE CC: HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment: Current Medications: PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: Family History: Social History: ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE Weight BMI Temp BP Height Pulse Resp PHYSICAL EXAMINATION General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric Lab Tests Special Tests Diagnosis Primary Diagnosis- Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses- Include three diagnoses PLAN including education o Plan: Further testing Medication Education Non-medication treatments Referrals Follow-up visits References