Below is the template you are to follow whendeveloping your management plan. Also, always be sure to complete the EMRon the case. Use this template with each case. It is not aSOAP format as that is not required. Points will be deducted for not utilizingthe template.
THIS SECTION IS 30 POINTS!!! Follow the bullet points below.Copy and answer each bullet point on a word document and cut and paste yourresponses to the management section!
- Primary Diagnosis and ICD-10 code: Also include any procedural codes.
- 3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
- Additional laboratory and diagnostic tests: It may be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patients insurance carrier.
- Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending it to the hospital, what orders would you write for a direct admit?
- Therapeutic modalities: pharmacological and nonpharmacological management.
- Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
- Patient education: Explanations and advice given to patient and family members.
- Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
- References (minimum of 3, timely, that prove this plan follows the current standard of care).
Identifyingdata (ID):lb a 76-year-old AfricanAmerican female that resides in an apartment on the second floor.
Chief complaint (CC): I am having pain in my knees and I amready to do something about it. That is why they sent me to you. My knees havebeen getting worse over the past couple of years. They hurt when I walk formore than a block and when I climb stairs.
Historyof present illness (HPI)
Analysis of symptom/complaint:
Lb complains of pain in her knees that staredabout five years ago but has gotten worse over time. The location of her painis inside her knees, and the pain in her right knee is worse. The pain in herright knee radiates down to her ankle. Ms. Johnson describes the pain in her knees as stiff and achy. They arestiff in the morning for about 15-20 minutes. Cold weather and exercise makesher knee pain worse. She hasnt found anything that helps with the pain. Ms.Johnson states that her pain level is usually about a 4 or 5 out of 10, andsometimes it is a 7 or 8 out of 10. Associated symptoms with the pain areswelling in her knees and sometimes her finger knuckles.
has trouble getting around duethe pain in her knees. Ms. Johnson states, I have to walk up the stairs to getto it. Thank goodness I dont live on the 3rd floor. Its gettingharder and harder to get up those stairs. My daughter usually has to come helpme.
a. Include significant chronic health disordersthat impact on the current chief complaint.
Ms. Johnson has a past medicalhistory of peptic ulcer disease with GI bleed from Ibuprofen use, chronickidney disease, and hypertension.
2. Allergies:Ms. Johnson denies allergies to medication, food, pollens and pet dander(environmental).
3. Immunizations: Up to date
4. Pastmedical history (PMH)
a. Pastmedical disorders/illnesses
Hypertension (for the last 20 years)
Chronic Kidney Disease
Peptic Ulcer Disease with GIbleed from Ibuprofen 4 years ago.
b. Pastsurgical history (PSH)
No past surgical history
Injuries/disabilities
Patientreports no injuries or disabilities.
d. Other hospitalizations B.
Medications
Amlodipine10mg tab ,1tab po daily
Lisinopril10mg tab,1 tab Po daily
Simvastatin20mg tab
Hydrochlorothiazide25mg tab
Acetaminophenprn headacge
Mulivitamindsily
