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 bulletpoints below. Copy and answer each bullet point on a word document and cut andpaste your responses 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).
Case information
I have this ugly looking rash on my upperthighs. The person that checked me in already took some pictures of it and putthem in my chart. You know, I can’t be 100% sure what all we walked throughwhile we were bush whacking, but it’s very possible. I think that area hasstuff like that growing on those hills. Yup. It was hot while we were hiking.But that’s no big deal. I’ve done that before with no problems.
Normally? Not really. My skin does appear to bea bit more sensitive than the average person’s though. Well, I have this rash.I mean it’s not a normal color for my skin. Would you say it looks like sores?It looks bad to me for sure! I first noticed some symptoms maybe a day and ahalf ago? Maybe 36 hours or so?
I went away with my boyfriend this past weekendto the Napa area and we did some hiking together. We sort of lost the trail abit and wound up bush whacking through some woods and brush to get back. It waspretty warm, like maybe 98, so I was wearing shorts, a tank top, sneakers andno socks. No big deal. We found our way back eventually. It was sort of fun. Wehad a really nice dinner with special treats I don’t ever have and enjoyed sometime in the hot tub together. It was really nice. Then maybe 24 hours after allmy symptoms started. Now maybe 12 hours after that, I have a big mess of arash.
No…. Well, now that I think of it, I usedsome of my boyfriend’s suntan lotion. It wasn’t my regular brand. I didn’tthink anything of it. Do you think that might be the problem?
Not that I remember. I was just out and aboutexploring a new location with my boyfriend. We stayed at this really coolAirbnb in Napa Valley.
I haven’t tried anything yet. I was hoping you could tell mewhat I should do about it. It’s really uncomfortable.
It’s starting to feel a little tender now.
I have this ugly looking rash on my upperthighs. The person that checked me in already took some pictures of it and putthem in my chart. You know, I can’t be 100% sure what all we walked throughwhile we were bush whacking, but it’s very possible. I think that area hasstuff like that growing on those hills. Yup. It was hot while we were hiking.But that’s no big deal. I’ve done that before with no problems.
Normally? Not really. My skin does appear to bea bit more sensitive than the average person’s though. Well, I have this rash.I mean it’s not a normal color for my skin. Would you say it looks like sores?It looks bad to me for sure! I first noticed some symptoms maybe a day and ahalf ago? Maybe 36 hours or so?
I went away with my boyfriend this past weekendto the Napa area and we did some hiking together. We sort of lost the trail abit and wound up bush whacking through some woods and brush to get back. It waspretty warm, like maybe 98, so I was wearing shorts, a tank top, sneakers andno socks. No big deal. We found our way back eventually. It was sort of fun. Wehad a really nice dinner with special treats I don’t ever have and enjoyed sometime in the hot tub together. It was really nice. Then maybe 24 hours after allmy symptoms started. Now maybe 12 hours after that, I have a big mess of arash.
No…. Well, now that I think of it, I usedsome of my boyfriend’s suntan lotion. It wasn’t my regular brand. I didn’tthink anything of it. Do you think that might be the problem?
Not that I remember. I was just out and aboutexploring a new location with my boyfriend. We stayed at this really coolAirbnb in Napa Valley.
I haven’t tried anything yet. I was hoping you could tell mewhat I should do about it. It’s really uncomfortable.
It’s starting to feel a little tender now.
