Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.

Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
2. Maeve, a 62-year-old widow, presents with an elevated papule that has a pearly appearance with a little crusting on her back above her bra strap. It’s about 8 mm and brown. She states that she didn’t even know it was there until she was wearing a bathing suit recently, and someone at the pool suggested that she have it checked out by a doctor. Since she’s now aware of it, she states that it itches.
EXAMPLE!!!!!!!
SOAP FORMAT
SUBJECTIVE:
Questions you will ask the patient……List questions!
HPI
PMHx
FHx
SHx
Medications
ROS
OBJECTIVE:
Vitals with BMI
Constitutional
HEENT
Cardiac
Pulmo
GI
Musculoskeletal
Skin
GU – if relevant
Always provide a very detailed physical exam, or descriiption of what you want to elicit on your physical exam on the organ system involved in your chief complaint
ASSESSMENT:
Working Diagnosis
– provide ICD 10 codes
– provide rationales or pertinent positives and negatives that made you consider the diagnosis
Differential # 1
– diagnosis you cannot miss.
– rationale why it can’t be missed
– provide ICD 10 code
Differential # 2
– what else could it be?
– rationale why you ruled it out
-provide ICD 10 Code
PLAN
DiagnosticsPharmacological Plan – indicate dosage and regimen, if not indicated state accordinglyHealth Education PlanReferral Plan – if not indicated, state accordinglyFollow-up plan – indicate when patient needs to follow-up and what symptoms to watch out forHealth promotion plan – age-specific health promotion recommendations not related to the case per USPTFNational Standards of Care/ Short Narrative for working diagnosis
REFERENCES