Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
Linda is a 45-year-old female who returns to the office four weeks after a slip and fall at home. Initially, she had some mild-to-moderate soreness that was alleviated with heat and occasional Aleve. She now presents with pain across her lower back, pain with sitting and standing, and radiation of pain and numbness through her right buttock and down through her right thigh. She is taking Aleve twice daily and Tylenol every eight hours with moderate relief of pain, but it doesn’t help with the numbness. The pain wakes her at night. There has been no change in her bladder or bowel habits.
Questions you will ask
Vitals with BMI
GU – if relevant
Always provide a very detailed physical exam, or descriiption of what you want to elicit on your physical exam on the organ system involved in your chief complaint
– provide ICD 10 codes
– provide rationales or pertinent positives and negatives that made you consider the diagnosis
Differential # 1
– diagnosis you cannot miss.
– rationale why it can’t be missed
– provide ICD 10 code
Differential # 2
– what else could it be?
– rationale why you ruled it out
-provide ICD 10 Code
Pharmacological Plan – indicate dosage and regimen, if not indicated state accordingly
Health Education Plan
Referral Plan – if not indicated, state accordingly
Follow-up plan – indicate when patient needs to follow-up and what symptoms to watch out for
Health promotion plan – age-specific health promotion recommendations not related to the case per USPTF
National Standards of Care/ Short Narrative for working diagnosis
EDUCATION—- patient education and national standards of care with source
REFERENCES Medical or peer-reviewed sources