Case study

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:

Diagnosis Signs/Symptoms Gold Standard Diagnostics

Gold Standard Treatment

Congestive Heart Failure

Unstable Angina

SVT (Supraventricular Tachycardia)

HTN

Hyperlipidemia

Acute Coronary Syndrome

Atrial Fibrillation

Deep Vein Thrombosis

Dissecting Aortic Aneurysm

Peripheral Artery Disease (PAD)