Week 4 Discussion
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SOAP format is the documentation style you will be using in your clinicals; this also adheres to the thought processes involved in formulating the correct diagnosis and treatment plan. You will present the subjective data first, including all questions that you want to ask. Next is the gathering of objective data that supports your subjective data; if there is none given, then you will determine by system what kind of physical exam elements you want to elicit. After this, you are ready to provide differentials and a working diagnosis based on the above data. After arriving at the appropriate working diagnosis, you will then formulate a treatment plan. Please be sure to follow the template below for your initial discussion board postings. Postings should be concise and NOT in narrative format. 
Template
Case Study Chosen: (List what case you have chosen) 
Demographics: Age/Gender 
SUBJECTIVE 
CC:  
HPI: (As listed from Case Study Information) 
Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).   
OBJECTIVE 
General: 
VS BP, HR, RR, Weight, Height, BMI   
Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)   
POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.     
ASSESSMENT 
Working Diagnosis:  (Must include ICD 10) 
Differential Diagnosis:  
PLAN
Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL. 
Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.  
Referrals: If Applicable  
Education: 
Health maintenance: 
RTC: 
Week 4 GI Discussion Prompts
A 25-year-old male graduate student is seen in the office with the chief complaint of upper abdominal pain. He states that he noticed the pain intermittently over the past several weeks. He notices that he gets a gnawing pain about 2 hours after he eats. He also notes that he has some bloating and occasional nausea with the pain. He states that the pain is relieved by antacids most of the time. 
A 34-year-old female presents with the complaint of sudden excruciating pain in her back and points to her flank area on the right side. She rates the pain as 10 on a scale of 1 to 10, with 10 being the worst. She also complains of nausea with the pain. She states that she has never had anything like this before, and the pain is subsiding a little now.?
A 30-year-old male comes in complaining of 2 days of loose to watery diarrhea, 4 to 5 times a day with significant nausea and one episode of vomiting today. He has a temperature of 100.5 on presentation and an HR of 102. His skin is slightly pale, and he is complaining of abdominal cramping. He states that he was in his usual state of health prior to the diarrhea and denies any unusual travel or food. His abdomen is generally tender with no rebound or guarding.?
Table 1. Common GI Diagnoses. In addition to your SOAP note, you must also complete the following table. Upload your SOAP note and table to the discussion board.