Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week\’s Learning Resources and consider the insights they provide.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
CASE STUDIES
Case Study : Focused Throat Exam
Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a âreally bad sore throatâ made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Childrenâs Motrin which made his fever better but did not help sore throat. He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue.
THE ASSIGNMENT
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\’s differential diagnosis and justify why you selected each.
**You will need to add in (MAKE UP) the missing information in the note, (some of the information you will have to MAKE UP i.e. meds, history, parts of the ROS and PE).
In the Assessment/Plan, you will document your differential diagnoses as per the assignment.
Your differential diagnoses should be HEENT conditions.
Case Study Assignment should be in the Episodic/Focused SOAP Note format rather
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