You are the group of Nurse Practitioners working at AGM Primary Care Medical Center. Develop the presentation of the Case Study as follows: 1. Dis
Specific Instructions
You are the group of Nurse Practitioners working at AGM Primary Care Medical Center. Develop the presentation of the Case Study as follows:
1. Discussion of assigned medical condition:
a) Description
1) Pathophysiology
2) Etiology
b) Clinical Manifestations
1) Red Flags
2. Case Study
a) Create a hypothetical case of a patient who comes to your consultation and whose final diagnosis is assigned.
b) History Data and Physical Examination
3. Case analysis – Diagnostic Framework
a) Apply the VINDICATE mnemonic as applicable. Explain what the relationship of the conditions is selected in the mnemonic with the diagnosis of the case.
4. Analysis of the case – Differential Diagnoses
a) Make the list of 5 differential diagnoses
1) In order of priority
2) Include clinical diagnosis of the case (previously assigned) on the list
5. Case analysis – Diagnostic Tests
a) Create a table, following the example described below, with the diagnostic test(s) that you would order to your patient in order to make the “Rule Out” of the differential diagnoses.
b) Include diagnostic tests in blood, and imaging studies, as applicable.
c) Explain what findings you are looking for with each test.
d) Describe the results obtained by your patient (hypothetical)
e) Be prepared to discuss the importance or relevance of the diagnostic tests you ordered.
Differential Diagnosis (Prioritize)
Diagnostic Tests
(ordered)
Findings expected with the diagnostic test
Patient results (hypothetical)
Analysis or Conclusion
1. Assigned Diagnosis
2. ¿?
3. ¿?
4. ¿?
5. ¿?
6. Complete the SOAP NOTE in all its parts with the information from your case study.
7. Prepare the case study in a Power Point presentation. Pay attention to the amount of information on the slides (do not overload them). Pay attention to the size of the font.
8. Close your presentation with a conclusion or final analysis and the references used.
PRIMARY CARE SOAP NOTE
Student: __________________________ Date: ______________
Professor: ______________________________________________________________
PATIENT INFORMATION:
NAME:
_______________________________________________________________________
AGE: ______________SEX: _______________
CC:__________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
SUBJECTIVE:
HPI:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________
PRIMARY CARE SOAP NOTE
______________________________________________________________________________
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ALLERGIES:
______________________________________________________________________________
______________________________________________________________________________
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CURRENTMEDICATIONS_____________________________________________________
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PMHX:_______________________________________________________________________
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FAMH:_______________________________________________________________________
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SOCHX:______________________________________________________________________
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PRIMARY CARE SOAP NOTE
REVIEW OF SYSTEMS:
CONSTITUTIONAL:__________________________________________________________
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HEENT:
HEAD:_______________________________________________________________________
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EYES:________________________________________________________________________
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EARS:_______________________________________________________________________
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NOSE:_______________________________________________________________________
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THROAT:____________________________________________________________________
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RESPIRATORY:
______________________________________________________________________________
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PRIMARY CARE SOAP NOTE
______________________________________________________________________________
CARDIOVASCULAR__________________________________________________________
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GASTROINTESTINAL:
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GENITOURINARY:
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MUSCULOSKELETAL: _______________________________________________________
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NEUROLOGIC:_______________________________________________________________
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PRIMARY CARE SOAP NOTE
OBJECTIVE:
CONSTITUTIONAL:
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SKIN:
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HEENT:
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NECK:
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RESPIRATORY:
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PRIMARY CARE SOAP NOTE
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CARDIOVASCULAR:
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GASTROINTESTINAL:
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PRIMARY CARE SOAP NOTE
GENITOURINARY:
______________________________________________________________________________
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PERIPHERAL VASCULAR:
______________________________________________________________________________
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MUSCULOSKELETAL:
______________________________________________________________________________
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NEUROLOGIC:
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PRIMARY CARE SOAP NOTE
ASSESSMENT:
DIAGNOSIS:
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DIFFERENTIAL DIAGNOSIS:
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PRIMARY CARE SOAP NOTE
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PLAN:
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Non-Pharmacologic treatment:
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PRIMARY CARE SOAP NOTE
Pharmacologic treatment:
MEDICATIONS:
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FOLLOW-UPS/REFERRALS:
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RATIONALE:
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PRIMARY CARE SOAP NOTE
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- Student:
- Date:
- AGE:
- SEX:
- CC 1:
- CC 2:
- CC 3:
- CC 4:
- HPI 1:
- HPI 2:
- HPI 3:
- HPI 4:
- HPI 5:
- HPI 6:
- HPI 7:
- HPI 8:
- HPI 9:
- HPI 10:
- HPI 11:
- HPI 12:
- HPI 13:
- HPI 14:
- HPI 15:
- HPI 16:
- HPI 17:
- HPI 18:
- HPI 19:
- HPI 20:
- HPI 21:
- HPI 22:
- HPI 23:
- HPI 24:
- 1:
- 2:
- 3:
- 4:
- ALLERGIES 1:
- ALLERGIES 2:
- ALLERGIES 3:
- ALLERGIES 4:
- CURRENTMEDICATIONS 1:
- CURRENTMEDICATIONS 2:
- CURRENTMEDICATIONS 3:
- CURRENTMEDICATIONS 4:
- PMHX 1:
- PMHX 2:
- PMHX 3:
- PMHX 4:
- FAMH 1:
- FAMH 2:
- FAMH 3:
- FAMH 4:
- FAMH 5:
- SOCHX 1:
- SOCHX 2:
- SOCHX 3:
- SOCHX 4:
- CONSTITUTIONAL 1:
- CONSTITUTIONAL 2:
- CONSTITUTIONAL 3:
- CONSTITUTIONAL 4:
- HEAD 1:
- HEAD 2:
- HEAD 3:
- HEAD 4:
- EYES 1:
- EYES 2:
- EYES 3:
- EARS 1:
- EARS 2:
- EARS 3:
- NOSE 1:
- NOSE 2:
- NOSE 3:
- THROAT 1:
- THROAT 2:
- THROAT 3:
- THROAT 4:
- RESPIRATORY 1:
- RESPIRATORY 2:
- RESPIRATORY 3:
- RESPIRATORY 4:
- CARDIOVASCULAR 1:
- CARDIOVASCULAR 2:
- CARDIOVASCULAR 3:
- CARDIOVASCULAR 4:
- CARDIOVASCULAR 5:
- CARDIOVASCULAR 6:
- GASTROINTESTINAL 1:
- GASTROINTESTINAL 2:
- GASTROINTESTINAL 3:
- GASTROINTESTINAL 4:
- GASTROINTESTINAL 5:
- GASTROINTESTINAL 6:
- GENITOURINARY 1:
- GENITOURINARY 2:
- GENITOURINARY 3:
- GENITOURINARY 4:
- GENITOURINARY 5:
- MUSCULOSKELETAL 1:
- MUSCULOSKELETAL 2:
- MUSCULOSKELETAL 3:
- MUSCULOSKELETAL 4:
- NEUROLOGIC 1:
- NEUROLOGIC 2:
- NEUROLOGIC 3:
- NEUROLOGIC 4:
- NEUROLOGIC 5:
- NEUROLOGIC 6:
- CONSTITUTIONAL 1_2:
- CONSTITUTIONAL 2_2:
- CONSTITUTIONAL 3_2:
- CONSTITUTIONAL 4_2:
- SKIN 1:
- SKIN 2:
- SKIN 3: </li
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