case study

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 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.

**Clinical Pearl**

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

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