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Demographics Subjective Data Case Study

SOAP format is the documentation style you will be using in your clinicals; this also adheres to the thought processes involved in formulating the correct diagnosis and treatment plan. You will present the subjective data first, including all questions that you want to ask. Next is the gathering of objective data that supports your subjective data; if there is none given, then you will determine by system what kind of physical exam elements you want to elicit. After this, you are ready to provide differentials and a working diagnosis based on the above data. After arriving at the appropriate working diagnosis, you will then formulate a treatment plan. Please be sure to follow the template below for your initial discussion board postings. Postings should be concise and NOT in narrative format.


Template

Case Study Chosen: (List what case you have chosen)

Demographics: Age/Gender

SUBJECTIVE

  • 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:

Week 5 Discussion Board Prompts – Musculoskeletal

  1. Susan is a 30-year-old registered nurse who works in transitional care. She presents to employee health stating, “My back is killing me. I was helping to transfer a patient and he moved. I thought he was going to fall, so I twisted around to grab onto him and wrenched my back. The pain is terrible, and I can barely walk.” Susan is a healthy young adult, married with a 5-year old. daughter. She has no significant family history. Susan has a past medical history of fractured coccyx as a teenager when she fell during cheerleading practice; no sequelae. She has smoked one-half pack of cigarettes a day since age 15 but is trying to quit. Current medicines include medroxyprogesterone acetate (Depo Provera) injection for birth control every 13 weeks. She is supposed to take calcium, but states that she “always forgets, and it constipates me anyway.” Susan denies any change in bowel/bladder habits.
  2. Mary is a 70-year-old widow with a history of osteoarthritis. She has been self-medicating with over-the-counter acetaminophen, either extra strength (500 mg/tablet) or arthritis strength (650mg/tablet) for over a year now. In addition to osteoarthritis, she also has osteoporosis and gastroesophageal reflux. She presents with the complaint of backache and right knee pain, aggravated by climbing stairs. She describes her knee pain as 8 on a scale of 1 to 10: “I can stand the back pain, but the knee is awful.” She lives alone but has two supportive daughters nearby. They take her shopping and help with housework. On good days, she goes to the senior center for lunch and socialization. She was doing exercises at the Senior Center but stopped due to her knee pain. She does not smoke or drink alcohol, except at birthday parties and celebrations. She denies any medication, food, or environmental allergies. In addition to the acetaminophen, medications include calcium with vitamin D, Protonix (pantoprazole), and an annual intravenous infusion of Reclast (zoledronic acid). She also has been taking a dietary supplement of glucosamine/chondroitin for 3 months. She recently had a complete physical examination with electrocardiogram and laboratory tests and was told that everything was “normal.”

  3. Linda is a 45-year-old female who returns to the office four weeks after a slip and fall at home. Initially, she had some mild-to-moderate soreness that was alleviated with heat and occasional Aleve. She now presents with pain across her lower back, pain with sitting and standing, and radiation of pain and numbness through her right buttock and down through her right thigh. She is taking Aleve twice daily and Tylenol every eight hours with moderate relief of pain, but it doesn’t help with the numbness. The pain wakes her at night. There has been no change in her bladder or bowel habits.

Table 1. Common Musculoskeletal Diagnoses. In addition to your SOAP note, 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
Low back pain/lumbago
Cauda Equina Syndrome
Plantar Fasciitis
Degenerative Joint Disease (Osteoarthritis)
Ankylosing Spondylitis
Meniscus Tear
Hip Fracture
Pelvic Fracture
Navicular Fracture
Colles Fracture
Ankle Sprain

**Clinical Pearl**

Type of Scan Indication Special Considerations
X-ray

Bone fractures/damage, OA, metal, dense objects

MRI Gold standard for injuries to cartilage, meniscus, tendons and ligaments

No metal, pacemakers, aneurysm clips

CT

Views structures like masses, trauma, fractures, bleeding. Forms 3-D picture

More cost effective than MRI

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