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 |
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
Follow-up visits |
References |