A 25-year-old male graduate student is seen in the office with the chief complaint of upper abdominal pain.
A 25-year-old male graduate student is seen in the office with the chief complaint of upper abdominal pain. He states that he noticed the pain intermittently over the past several weeks. He notices that he gets a gnawing pain about 2 hours after he eats. He also notes that he has some bloating and occasional nausea with the pain. He states that the pain is relieved by antacids most of the time.
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 GI Diagnoses. In addition to your SOAP note, you must also complete the following table.
Diagnosis Signs/Symptoms Gold Standard Diagnostics Gold Standard Treatment
Acute Appendicitis
Acute Cholecystitis
Acute Diverticulitis
Clostridium difficile Colitis (C-diff)
GERD
Irritable Bowel Syndrome (IBS)
Duodenal Ulcer
Acute Pancreatitis
Crohn’s Disease
Ulcerative Colitis
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