CC – The reason for the visit, as stated in the patient’s own words
Example: “I have a painful rash on my left side that started two days ago.”
HPI (History of Present Illness) – include symptom dimensions and the chronological narrative of the patient’s complaints. Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information. If the information is obtained from other sources, always identify the source.
PMH (Pertinent past medical history)
Medications – Current medications (list with daily dosages).
Allergies
Pertinent Family History, Social History, and other subjective data if relevant to the patient’s presenting problem and diagnosis.
ROS (Pertinent review of systems) – a system-based list of questions that help uncover symptoms not otherwise mentioned by the patient. Only include systems pertinent to the presenting problem and diagnosis in a focused SOAP note.
Vital signs
PE–focused physical exam findings are limited to systems pertinent to the problem
Laboratory or diagnostic data, if applicable
Differential diagnoses (with ICD 10 code)– distinguishing a particular disease or condition from others with similar clinical features. Identify 2. Provide a brief rationale (3-4 sentences) and cite – rationale should provide data that support your differential diagnoses – presentation, PE finding, and lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and the laboratory/diagnostic tests that would make the diagnosis.
Working Diagnosis (with ICD 10 code)– What is the problem? Provide supporting data (cite).
This has to be evidence-based (cite) using the latest clinical guidelines. This should include pharmacologic, non-pharmacologic, education, referrals, and follow-up – when applicable. The plan should be personalized and appropriate for the patient.
Cite and provide references.
Personal Data
Name: Tina Jones
Age: 28years
Gender: Female
Race: African American
Subjective Data
Chief complaint: Throat pain
History of presenting illness: Tina Jones is a 28-year-old African American female at the emergency department due to throat pain when swallowing. The pain is gradual onset, intermittent, and on a scale of 4 out of 10 in the morning. It has no specific aggravating factors. The patient reports severe and recurrent throat, eyes, and nose itchiness. She complains of a runny nose all day and a weekly headache. She denies environmental exposure to irritants. She refuses changes in her hearing, vision, and taste, shortness of breath, wheezing, cough, fevers, chills, and night sweats.
Current medication: Tylenol 1g PO daily for headache, lozenges one tablet to relieve sore throat and inhaler 2-3 times weekly for asthma.
Past medical history: The patient has had asthma since the age of 16 years. Her immunization schedule is up to date. Her last COVID booster vaccine was three months ago. She denies hospitalization and blood transfusion.
Past surgical history: none
Allergies: The patient is allergic to dust and cats.
Family history: She is the firstborn in a family of three. Her mother has asthma and recurrent upper respiratory tract infections. Her father has hypertension and recurrent allergic rhinitis. Her younger sister develops hay fever when exposed to pollen. Her younger brother has allergic rhinitis. She denies a family history of cancer, mental health disorders, and lifestyle diseases.
Social history: The patient is single and lives alone. She works as an accountant in a cooperative savings society. She has a bachelor’s in commerce and accountancy. She occasionally takes two bottles of beer in the company of her friends. She denies using tobacco and bhang. She enjoys coffee, deep-fried fish, and fries for lunch. Her house has smoke detectors, she uses seat belts when driving, and she does not use her phone in the pathways.
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