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Specific Instructions

You are the group of Nurse Practitioners working at AGM Primary Care Medical Center. Develop the presentation of the Case Study as follows:

1. Discussion of assigned medical condition:

a) Description

1) Pathophysiology

2) Etiology

b) Clinical Manifestations

1) Red Flags

2. Case Study

a) Create a hypothetical case of a patient who comes to your consultation and    whose final diagnosis is assigned.

b) History Data and Physical Examination

3. Case analysis – Diagnostic Framework

a) Apply the VINDICATE mnemonic as applicable. Explain what the relationship    of the conditions is selected in the mnemonic with the diagnosis of the case.

4. Analysis of the case – Differential Diagnoses

a) Make the list of 5 differential diagnoses

1) In order of priority

2) Include clinical diagnosis of the case (previously assigned) on the list

5. Case analysis – Diagnostic Tests

a) Create a table, following the example described below, with the diagnostic    test(s) that you would order to your patient in order to make the “Rule Out” of    the differential diagnoses.

b) Include diagnostic tests in blood, and imaging studies, as applicable.

c) Explain what findings you are looking for with each test.

d) Describe the results obtained by your patient (hypothetical)

e) Be prepared to discuss the importance or relevance of the diagnostic tests you   ordered.

Differential Diagnosis (Prioritize)

Diagnostic Tests

(ordered)

Findings expected with the diagnostic test

Patient results (hypothetical)

Analysis or Conclusion

1. Assigned Diagnosis

2. ¿?

3. ¿?

4. ¿?

5. ¿?

6. Complete the SOAP NOTE in all its parts with the information from your case study.

7. Prepare the case study in a Power Point presentation. Pay attention to the amount of  information on the slides (do not overload them). Pay attention to the size of the font.

8. Close your presentation with a conclusion or final analysis and the references used.

PRIMARY CARE SOAP NOTE

Student: __________________________ Date: ______________

Professor: ______________________________________________________________

PATIENT INFORMATION:

NAME:

_______________________________________________________________________

AGE: ______________SEX: _______________

CC:__________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

SUBJECTIVE:

HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

PRIMARY CARE SOAP NOTE

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

ALLERGIES:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

CURRENTMEDICATIONS_____________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PMHX:_______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

FAMH:_______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SOCHX:______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

REVIEW OF SYSTEMS:

CONSTITUTIONAL:__________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

HEENT:

HEAD:_______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EYES:________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EARS:_______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

NOSE:_______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

THROAT:____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

RESPIRATORY:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

______________________________________________________________________________

CARDIOVASCULAR__________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

GASTROINTESTINAL:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

GENITOURINARY:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

MUSCULOSKELETAL: _______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

NEUROLOGIC:_______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

OBJECTIVE:

CONSTITUTIONAL:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SKIN:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

________________________________________________________________________

HEENT:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________

NECK:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

RESPIRATORY:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

CARDIOVASCULAR:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

GASTROINTESTINAL:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

GENITOURINARY:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PERIPHERAL VASCULAR:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

MUSCULOSKELETAL:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

NEUROLOGIC:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

________________________________________________________________

PRIMARY CARE SOAP NOTE

ASSESSMENT:

DIAGNOSIS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

DIFFERENTIAL DIAGNOSIS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________

PLAN:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

________________________________________________________________________

Non-Pharmacologic treatment:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

Pharmacologic treatment:

MEDICATIONS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

FOLLOW-UPS/REFERRALS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

RATIONALE:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRIMARY CARE SOAP NOTE

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

  1. Student:
  2. Date:
  3. AGE:
  4. SEX:
  5. CC 1:
  6. CC 2:
  7. CC 3:
  8. CC 4:
  9. HPI 1:
  10. HPI 2:
  11. HPI 3:
  12. HPI 4:
  13. HPI 5:
  14. HPI 6:
  15. HPI 7:
  16. HPI 8:
  17. HPI 9:
  18. HPI 10:
  19. HPI 11:
  20. HPI 12:
  21. HPI 13:
  22. HPI 14:
  23. HPI 15:
  24. HPI 16:
  25. HPI 17:
  26. HPI 18:
  27. HPI 19:
  28. HPI 20:
  29. HPI 21:
  30. HPI 22:
  31. HPI 23:
  32. HPI 24:
  33. 1:
  34. 2:
  35. 3:
  36. 4:
  37. ALLERGIES 1:
  38. ALLERGIES 2:
  39. ALLERGIES 3:
  40. ALLERGIES 4:
  41. CURRENTMEDICATIONS 1:
  42. CURRENTMEDICATIONS 2:
  43. CURRENTMEDICATIONS 3:
  44. CURRENTMEDICATIONS 4:
  45. PMHX 1:
  46. PMHX 2:
  47. PMHX 3:
  48. PMHX 4:
  49. FAMH 1:
  50. FAMH 2:
  51. FAMH 3:
  52. FAMH 4:
  53. FAMH 5:
  54. SOCHX 1:
  55. SOCHX 2:
  56. SOCHX 3:
  57. SOCHX 4:
  58. CONSTITUTIONAL 1:
  59. CONSTITUTIONAL 2:
  60. CONSTITUTIONAL 3:
  61. CONSTITUTIONAL 4:
  62. HEAD 1:
  63. HEAD 2:
  64. HEAD 3:
  65. HEAD 4:
  66. EYES 1:
  67. EYES 2:
  68. EYES 3:
  69. EARS 1:
  70. EARS 2:
  71. EARS 3:
  72. NOSE 1:
  73. NOSE 2:
  74. NOSE 3:
  75. THROAT 1:
  76. THROAT 2:
  77. THROAT 3:
  78. THROAT 4:
  79. RESPIRATORY 1:
  80. RESPIRATORY 2:
  81. RESPIRATORY 3:
  82. RESPIRATORY 4:
  83. CARDIOVASCULAR 1:
  84. CARDIOVASCULAR 2:
  85. CARDIOVASCULAR 3:
  86. CARDIOVASCULAR 4:
  87. CARDIOVASCULAR 5:
  88. CARDIOVASCULAR 6:
  89. GASTROINTESTINAL 1:
  90. GASTROINTESTINAL 2:
  91. GASTROINTESTINAL 3:
  92. GASTROINTESTINAL 4:
  93. GASTROINTESTINAL 5:
  94. GASTROINTESTINAL 6:
  95. GENITOURINARY 1:
  96. GENITOURINARY 2:
  97. GENITOURINARY 3:
  98. GENITOURINARY 4:
  99. GENITOURINARY 5:
  100. MUSCULOSKELETAL 1:
  101. MUSCULOSKELETAL 2:
  102. MUSCULOSKELETAL 3:
  103. MUSCULOSKELETAL 4:
  104. NEUROLOGIC 1:
  105. NEUROLOGIC 2:
  106. NEUROLOGIC 3:
  107. NEUROLOGIC 4:
  108. NEUROLOGIC 5:
  109. NEUROLOGIC 6:
  110. CONSTITUTIONAL 1_2:
  111. CONSTITUTIONAL 2_2:
  112. CONSTITUTIONAL 3_2:
  113. CONSTITUTIONAL 4_2:
  114. SKIN 1:
  115. SKIN 2:
  116. SKIN 3:
  117. SKIN 4:
  118. HEENT 1:
  119. HEENT 2:
  120. HEENT 3:
  121. HEENT 4:
  122. HEENT 5:
  123. HEENT 6:
  124. HEENT 7:
  125. HEENT 8:
  126. HEENT 9:
  127. HEENT 10:
  128. HEENT 11:
  129. HEENT 12:
  130. HEENT 13:
  131. HEENT 14:
  132. NECK 1:
  133. NECK 2:
  134. NECK 3:
  135. NECK 4:
  136. NECK 5:
  137. RESPIRATORY 1_2:
  138. RESPIRATORY 2_2:
  139. RESPIRATORY 3_2:
  140. RESPIRATORY 4_2:
  141. RESPIRATORY 5:
  142. 1_2:
  143. 2_2:
  144. 3_2:
  145. 4_2:
  146. 5:
  147. 6:
  148. 7:
  149. 8:
  150. 9:
  151. 10:
  152. 11:
  153. 12:
  154. CARDIOVASCULAR 1_2:
  155. CARDIOVASCULAR 2_2:
  156. CARDIOVASCULAR 3_2:
  157. CARDIOVASCULAR 4_2:
  158. CARDIOVASCULAR 5_2:
  159. CARDIOVASCULAR 6_2:
  160. CARDIOVASCULAR 7:
  161. CARDIOVASCULAR 8:
  162. CARDIOVASCULAR 9:
  163. CARDIOVASCULAR 10:
  164. CARDIOVASCULAR 11:
  165. CARDIOVASCULAR 12:
  166. GASTROINTESTINAL 1_2:
  167. GASTROINTESTINAL 2_2:
  168. GASTROINTESTINAL 3_2:
  169. GASTROINTESTINAL 4_2:
  170. GASTROINTESTINAL 5_2:
  171. GASTROINTESTINAL 6_2:
  172. GASTROINTESTINAL 7:
  173. GASTROINTESTINAL 8:
  174. GASTROINTESTINAL 9:
  175. GASTROINTESTINAL 10:
  176. GASTROINTESTINAL 11:
  177. GENITOURINARY 1_2:
  178. GENITOURINARY 2_2:
  179. GENITOURINARY 3_2:
  180. GENITOURINARY 4_2:
  181. GENITOURINARY 5_2:
  182. GENITOURINARY 6:
  183. GENITOURINARY 7:
  184. GENITOURINARY 8:
  185. GENITOURINARY 9:
  186. GENITOURINARY 10:
  187. GENITOURINARY 11:
  188. GENITOURINARY 12:
  189. PERIPHERAL VASCULAR 1:
  190. PERIPHERAL VASCULAR 2:
  191. PERIPHERAL VASCULAR 3:
  192. PERIPHERAL VASCULAR 4:
  193. PERIPHERAL VASCULAR 5:
  194. MUSCULOSKELETAL 1_2:
  195. MUSCULOSKELETAL 2_2:
  196. MUSCULOSKELETAL 3_2:
  197. MUSCULOSKELETAL 4_2:
  198. MUSCULOSKELETAL 5:
  199. MUSCULOSKELETAL 6:
  200. MUSCULOSKELETAL 7:
  201. MUSCULOSKELETAL 8:
  202. MUSCULOSKELETAL 9:
  203. NEUROLOGIC 1_2:
  204. NEUROLOGIC 2_2:
  205. NEUROLOGIC 3_2:
  206. NEUROLOGIC 4_2:
  207. NEUROLOGIC 5_2:
  208. NEUROLOGIC 6_2:
  209. NEUROLOGIC 7:
  210. DIAGNOSIS 1:
  211. DIAGNOSIS 2:
  212. DIAGNOSIS 3:
  213. DIAGNOSIS 4:
  214. 1_3:
  215. 2_3:
  216. 3_3:
  217. MEDICATIONS 1:
  218. MEDICATIONS 2:
  219. MEDICATIONS 3:
  220. MEDICATIONS 4:
  221. MEDICATIONS 5:
  222. MEDICATIONS 6:
  223. MEDICATIONS 7:
  224. MEDICATIONS 8:
  225. MEDICATIONS 9:
  226. MEDICATIONS 10:
  227. MEDICATIONS 11:
  228. MEDICATIONS 12:
  229. MEDICATIONS 13:
  230. MEDICATIONS 14:
  231. MEDICATIONS 15:
  232. FOLLOWUPSREFERRALS 1:
  233. FOLLOWUPSREFERRALS 2:
  234. FOLLOWUPSREFERRALS 3:
  235. FOLLOWUPSREFERRALS 4:
  236. FOLLOWUPSREFERRALS 5:
  237. RATIONALE 1:
  238. RATIONALE 2:
  239. RATIONALE 3:
  240. RATIONALE 4:
  241. RATIONALE 5:
  242. RATIONALE 6:
  243. RATIONALE 7:
  244. RATIONALE 8:
  245. RATIONALE 9:
  246. RATIONALE 10:
  247. RATIONALE 11:
  248. RATIONALE 12:
  249. RATIONALE 13:
  250. 1_4:
  251. 2_4:
  252. 3_4:
  253. 4_3:
  254. 5_2:
  255. Text1:
  256. Text2:
  257. Text3:
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