To Prepare:
Review this week’s Learning Resources. Consider preventative health and assessing, diagnosing, and treating
special populations.
Review the case study provided by your Instructor. Based on the provided patient information, think about the
health history you would need to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate in order to gather more information
about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
Develop a preventative health treatment plan for the patient that includes health promotion and patient
education strategies for special populations.
Complete:
Use the Focused SOAP Note Template to address the following:
Subjective: What details are provided regarding the patient’s personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and
negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial
issues.
Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority
to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary
diagnosis be and why?
Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and
management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up
parameters as well as a rationale for this treatment and management plan.
Reflection notes: Describe your “aha!” moments from analyzing this case
Sample Solution