w 7 Discussion

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:

Differential Signs/Symptoms Gold Standard Diagnostics

Gold Standard Treatment

Ex: PTSD

Flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, agoraphobia, sleep disturbance and hypervigilance, feelings of detachment.

Clinician- Administered PTSD Scale (CAPS-5)

First-line treatment with a trauma- focused psychotherapy such as eye movement desensitization and reprocessing (EMDR). In individuals with comorbid disorders (ex., depression, psychosis) that affect the person’s ability to work in trauma-focused therapy (ex., concentration, motivation), treat with pharmacologic management; SSRI first line such as sertraline or paroxetine.

1.

2.

3.

4.

5.