Year Male Presents Assignment Help: How to Answer This Question
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Original Question
2. A 48-year-old male presents with a two-month history of nighttime headaches that are becoming more frequent. The pain awakens him at night. He has no other somatic complaints and no other significant medical history. What are your initial diagnosis, differential diagnosis, and treatment plan? In SOAP format as advised below? SUBJECTIVE: Questions you will ask HPI PMHx FHx SHx Medications ROS OBJECTIVE: Vitals with BMI Constitutional HEENT Cardiac Pulmo GI Musculoskeletal Skin GU – if relevant Always provide a very detailed physical exam, or description of what you want to elicit on your physical exam on the organ system involved in your chief complaint ASSESSMENT: Working Diagnosis – 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 PLAN Diagnostics 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
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