Treatment and management plan
| CLINICAL CASE SCENARIO |
| A mother brings her 18-month-old son to your clinic because of a persistent facial rash. The child is restless at night and scratches in her sleep. He is otherwise healthy. Today, his vitals are as follows: weight 23.4 lbs, height 31.8 inches, BP 120/76, HR 100, RR 26, and Temperature is 98.6 F. His physical examination reveals a well-nourished, healthy-appearing child with dry, red, scaly areas on the cheeks, chin, and around the mouth as well as on the extensor surfaces of his extremities. The areas on the cheeks have a plaque-like, weepy appearance. The diaper area is spared. The remainder of the child’s examination is normal. Diagnosis – Atopic Dermatitis |
As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below: FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment: DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE. SUBJECTIVE (S): Describes what the patient reports about their condition. For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION. Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies. Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc… SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.
Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)
HRB (Health-related behaviors): ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).
OBJECTIVE: Physical findings you observe or find on the exam. 1. Age, gender, general appearance 2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart 3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has) 4. Lab Section – what results do you have? 5. Studies/Radiology/Pap Results Section – what results do you have? RISK FACTORS: List risk factors for the acute and chronic conditions ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.
You are to also list any chronic conditions with the ICD-10 codes. NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions. Example: 1. HTN a) Vaccines administered this visit & vaccine administration forms given, b) Medication-include dosage amounts and mg/kg for drug and number of days, c) Laboratory tests ordered d) Diagnostic tests ordered e) Non-pharmaceutical treatments f) Patient/Family education including preventive care 2. HLD a) Vaccines administered this visit & vaccine administration forms given, b) Medication-include dosage amounts and mg/kg for drug and number of days, c) Laboratory tests ordered d) Diagnostic tests ordered e) Non-pharmaceutical treatments f) Patient/Family education including preventive care Also discussed: g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section) Return to the clinic: h) Follow-up appointment with a detailed plan for f/u and any referrals
