Sickle Cell Disease
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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