Sickle Cell Disease – Savvy Essay Writers | savvyessaywriters.net
Sickle Cell Disease – Savvy Essay Writers | savvyessaywriters.net
The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part.
The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan.
The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.
| Patient Initials: | Pt. Encounter Number: | |
| Date: | Age: | Sex: |
| Allergies: Advanced Directives: | ||
| SUBJECTIVE | ||
| CC: | ||
| HPI: Describe the course of the patient’s illness:
Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment: |
||
| Current Medications: | ||
| PMH
Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: |
||
| Family History: | ||
| Social History: | ||
| ROS | ||
| General | Cardiovascular | |
| Skin | Respiratory | |
| Eyes | Gastrointestinal | |
| Ears | Genitourinary/Gynecological |
| Nose/Mouth/Throat | Musculoskeletal | |
| Breast | Neurological | |
| Heme/Lymph/Endo | Psychiatric | |
| OBJECTIVE | ||
| Weight BMI | Temp | BP |
| Height | Pulse | Resp |
| PHYSICAL EXAMINATION | ||
| General Appearance | ||
| Skin | ||
| HEENT | ||
| Cardiovascular | ||
| Respiratory | ||
| Gastrointestinal | ||
| Breast | ||
| Genitourinary | ||
| Musculoskeletal | ||
| Neurological | ||
| Psychiatric | ||
| Lab Tests |
| Special Tests |
| Diagnosis |
| · Primary Diagnosis-
Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses– Include three diagnoses PLAN including education o Plan: Further testing Medication Education Non-medication treatments · Referrals Follow-up visits |
| References |
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