Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.
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:
Table 1. Common Respiratory Diagnoses. If you completed your SOAP note on a Respiratory Prompt, you must also complete the following table.
Diagnosis
Signs/Symptoms
Gold Standard Diagnostics
Gold Standard Treatment
COPD
Community Acquired Pneumonia
Atypical Pneumonia
Acute Bronchitis
Asthma
Tuberculosis
Pulmonary Emboli
COVID-19
Upper Respiratory Infection
Influenza
