Differential Diagnoses in Patients

Assignment:
• Choose a patient with one or two disease entities, if possible. Routine or annual exams are great.
• Make a photocopy of the actual SOAP Note or progress note that you charted at the clinical agency, Remove all identifying patient information from the original SOAP Note.
• The SOA is to be written according to APA (7th edition). Include a title page, proper citations, and reference list. Each note should be submitted as an attached Word document in the assignment submission tab for that SOA note.
• Reference at least three current published sources that support your differential diagnoses, working diagnosis, and must not miss diagnosis. The sources may include current textbooks, peer reviewed journals and websites commonly used by primary care providers. If you use a website as a reference, you must submit a completed evaluation of the site using guidelines posted in the course.
• Provide 3 differential diagnoses for each problem.

• Document in a clear concise and accurate manner.
• Use the following guidelines

Subjective – Objective – Assessment Notes

Address Subjective data, Objective data, and provide a diagnosis or assessment for the patient being documented, but do not include a plan for care, (the “P” in SOAP notes). The format for the S-O-A note is provided below.

These notes are to be based on patients you see with your preceptor in your general adult primary care setting for episodic illness and injury visits.

Listen closely to the patient responses for subjective data and, if allowed, collect objective data yourself along with your preceptor’s examination. It is assumed that the preceptor is the person responsible for the assessment and making the diagnosis for the real patient and completing the medical record, not the student. The student is practicing the recording of data from the visit and the chart in the S-O-A format. The goal for the assignment is that you can accurately identify data bits as subjective or objective and that you come to see how the accumulated data illustrates the diagnosis.

In the Seidel textbook you will find guidelines regarding documentation of findings. Use this material to understand the content and organization of Subjective and Objective data within a SOAP note.

Below is a general outline. For patients being seen for a focused visit, some data may not be collected, but data relevant to the visit may have been recorded in the patient’s record previously. Read the chart as well as participate in the visit. For focused visits, a complete head-to-toe physical examination may not be appropriate. Document the physical examination as directed by your preceptor.

Use an outline format for your S-O-A note, with headings and sub-headings to organize your data:

Subjective data

a) Identifying information is given with each S-O-A note:
(1) Age of client
(2) Source of information and estimation of the person’s reliability
b) Chief Complaint reason for visit in patient’s own words and duration of symptoms
c) History of the Present Illness
d) Past medical history
e) Past surgical history
f) Family medical history
g) Social and environmental history
h) Review of Systems pertinent to the chief complaint (to be documented “head-to-toe,” order)

Objective data (focused physical exam to be documented in “head-to-toe,” order)

a) General survey
b) Head, Eyes, Ears, Nose, Oral cavity, Throat (include mouth and neck, lymph nodes here also)
c) Chest (include axillary lymph nodes)
(a) Thorax
(b) Heart
(c) Lungs
d) Abdomen (include inguinal lymph nodes)
e) Extremities
(a) Muscles, bones, joints
(b) Peripheral vascular
f) Neurological

Assessment

List three potential differential diagnoses for each problem you assessed and your rationale for each as established by your preceptor. Choose the most likely one of these diagnoses as the working diagnosis and tell us why it is the best fit for the patient’s symptoms. Include the must not miss diagnosis. Include the ICD-10 code for that diagnosis.
The rewrite is basically the SOA Note you wish you had written. It should include the focused History and Physical representing your episodic encounter with a patient. It may be a complete History and Physical or an episodic visit. ONE OF THE SOA NOTES NEEDS TO BE AN ANNUAL PHYSICAL. IF THIS IS A PROBLEM AT YOUR FACILITY, NOTIFY your professor. Use your books to help you write the note and individualize it for your patients.