Below is the template you are to follow when
developing your management plan. Also, always be sure to complete the EMR
on the case. Use this template with each case. It is not a
SOAP format as that is not required. Points will be deducted for not utilizing
THIS SECTION IS 30 POINTS!!! Follow the bullet points below.
Copy and answer each bullet point on a word document and cut and paste your
responses to the management section!
- Primary Diagnosis and ICD-10
code: Also include any procedural codes.
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.
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
patientâ€™s 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?
and nonpharmacological management.
Promotion: Address risk factors as
appropriate. Consider age-appropriate preventive health screening.
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).
data (ID):lb a 76-year-old African
American female that resides in an apartment on the second floor.
Chief complaint (CC): â€œI am having pain in my knees and I am
ready to do something about it. That is why they sent me to you. My knees have
been getting worse over the past couple of years. They hurt when I walk for
more than a block and when I climb stairs. â€œ
of present illness (HPI)
Analysis of symptom/complaint:
Lb complains of pain in her knees that stared
about five years ago but has gotten worse over time. The location of her pain
is inside her knees, and the pain in her right knee is worse. The pain in her
right knee radiates down to her ankle.
Ms. Johnson describes the pain in her knees as stiff and achy. They are
stiff in the morning for about 15-20 minutes. Cold weather and exercise makes
her knee pain worse. She hasnâ€™t found anything that helps with the pain. Ms.
Johnson states that her pain level is usually about a 4 or 5 out of 10, and
sometimes it is a 7 or 8 out of 10. Associated symptoms with the pain are
swelling in her knees and sometimes her finger knuckles.
has trouble getting around due
the pain in her knees. Ms. Johnson states, â€œI have to walk up the stairs to get
to it. Thank goodness I donâ€™t live on the 3rd floor. Itâ€™s getting
harder and harder to get up those stairs. My daughter usually has to come help
Include significant chronic health disorders
that impact on the current chief complaint.
Ms. Johnson has a past medical
history of peptic ulcer disease with GI bleed from Ibuprofen use, chronic
kidney disease, and hypertension.
Ms. Johnson denies allergies to medication, food, pollens and pet dander
Immunizations: Up to date
medical history (PMH) â€“
Hypertension (for the last 20 years)
Chronic Kidney Disease
Peptic Ulcer Disease with GI
bleed from Ibuprofen 4 years ago.
surgical history (PSH)
No past surgical history
reports no injuries or disabilities.
d. Other hospitalizations B.
10mg tab ,1tab po daily
10mg tab,1 tab Po daily