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 the template.
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.
- 3-5 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.
- Additional 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 patient’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?
- Therapeutic modalities: pharmacological and nonpharmacological management.
- Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
- Patient 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).
Harvey HoyaProblem ListH.H. is a 57 y.o. overweight Hispanic construction worker who presents for evaluation of an elevated blood pressure reading at a recent local health fair. He reports “some” shortness of breath with moderate exertion, intermittent headaches, and interrupted sleep with snoring. Physical examination is notable BP 172/94 L and 178/98 R after 5 minutes of rest; laterally displaced PMI; and funduscopic findings of A-V nicking. Was told he had elevated BP in the past,but took no action. FH is positive for hypertension and related complications. Diagniosis primary hypertensionDifferential diagnosis White coat hyperternsion