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