CC:
HPI: (As listed from Case Study Information)
Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).
OBJECTIVE
General:
VS BP, HR, RR, Weight, Height, BMI
Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)
POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.
ASSESSMENT
Working Diagnosis: (Must include ICD 10)
Differential Diagnosis:
PLAN
Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.
Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
Referrals: If Applicable
Education:
Health maintenance:
RTC:
Respiratory Discussion Prompts
Sandy is a 64-year-old patient with a 10-year history of recurrent sinusitis. She presents to your primary care clinic today complaining of “head congestion.” She also reports that she had a “cold” last week with symptoms of cough and “runny nose.” Two days ago, she developed a headache that was “worse” when bending over but improved with Tylenol. She describes the headache as a “3 out of 10” and says it is primarily a “frontal headache.” She also reports that her nasal congestion has become worse. She has been blowing her nose even more, and the discharge from her nose has become thicker, with a yellow-green color. She has been taking pseudoephedrine for the past 48 hours with little relief of her nasal congestion. She denies tooth pain or pain on chewing. She has no past history of seasonal allergies, although she was treated for sinusitis 6 months ago in your clinic as well as approximately one year ago.
The remainder of her medical history is essentially negative. Her temperature taken at the clinic is 99.6°F. On physical examination, she has tenderness to palpation in the frontal area and no maxillary tenderness, and nasal mucosa is erythematous as is her pharynx. Her submaxillary nodes are enlarged bilaterally, but there is no cervical lymphadenopathy. Her lungs are clear to auscultation. Her heart has a regular rate and rhythm and is negative for murmurs, gallops, and rubs. Her vital signs are:
Blood pressure:128/88; Pulse: 78 and regular; Respiratory rate: 20 p/min, non-labored.
Mason is a 55-year-old homeless man who you are seeing today for the first time. He is a smoker and states that he has frequent colds and a routine morning cough. He used to be short of breath just walking up hills, but he now has difficulty breathing with everyday activities and is having trouble finding food because he cannot walk very far. He just wants medicine to help him survive on the streets. On examination, you find him using his accessory muscles to breathe. His vital signs are 99°, 100 beats per minute, 28 respirations/min., and blood pressure 140/90. Breath sounds are distant with end-expiratory wheezes. He has a slight barrel chest and neck vein distention.
Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.
Calvin is a 36-year-old lawyer who is coming in today for a worsening cough over the past four days. He has had some yellow sputum sporadically throughout the day; he says he has felt hot but has not taken his temperature. He has a history of asthma and has been using his Proventil inhaler every 2 to 3 hours for the past 3 to 4 days. He has no other medication. He says that other than the cough, he feels a little fatigued, and he notices that his energy level is less when he plays hockey with his men’s league twice a week. His SaO2 is 96%, HR 102, and BP 144/82. He has bilateral wheezes posteriorly on inspiration, worse at the base.
Table 1. Common Respiratory Diagnoses. If you completed your SOAP note on a Respiratory Prompt, you must also complete the following table. Upload your SOAP note and table to the discussion board.
Diagnosis Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment
COPD
Community Acquired Pneumonia
Atypical Pneumonia
Acute Bronchitis
Asthma
Tuberculosis
Pulmonary Emboli
COVID-19
Upper Respiratory Infection
Influenza
Cardiovascular Discussion Prompts
Jim is a 69-year-old male who comes in today complaining of dyspnea on exertion, and you have noted that he has gained about 25 pounds since his last visit 7 months ago. He tells you that he is not sleeping at night because of a constant cough, and he thinks he has a cold because he is coughing up pink frothy “spit”. He is extremely fatigued because of his lack of sleep. Your examination reveals bilateral 3+ pitting edema with his lower extremities being cool to the touch, distended abdomen, hepatomegaly, hacking cough, and S3 with a gallop. Jim had a myocardial infarction (MI) 15 years ago, and his currently on medication for hypertension.
Matthew is a 52-year-old truck driver who is seeing you today for his physical. He states that he has been in his usual state of health but missed his physical for the past few years. His BP is 165/90, HR 90, Height is 6’2, and Weight is 204. Total Cholesterol 244, HDL 32 LDL 166 Triglycerides 344 A1C 6.8.
Jennifer is an 84-year-old who recently returned from London with her husband. She comes to your clinic as a walk-in from the airport because she does not feel well. She has felt shaky, a little short of breath, and slightly light-headed for the past 2 to 3 hours. She did not take her Norvasc or Lisinopril this morning because she didn’t feel well. She presents to you slightly diaphoretic. Her BP is 90/50, HR is 155, and RR 20. She is alert and oriented.
Table 2. Common Cardiovascular Diagnoses. If you completed your SOAP note on a Cardiovascular Prompt, you must also complete the following table. Upload your SOAP note and table to the discussion board.
Diagnosis Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment
Congestive Heart Failure
Unstable Angina
SVT (Supraventricular Tachycardia)
HTN
Hyperlipidemia
Acute Coronary Syndrome
Atrial Fibrillation
Deep Vein Thrombosis
Dissecting Aortic Aneurysm
Peripheral Artery Disease (PAD)
