Reference no: EM133219014

Kylie, a 24-year-old female patient, comes to your office for a refill of her allergy medication. Before going into the room, you note that her Patient Health Questionnaire - Depression (PHQ-9) score is 20, and that she is not currently on any medication for depression. When you enter the room, you notice that Kylie is easily startled, and she is sitting in the corner of the room very close to the wall.

What questions you would ask the patient? In the following SOAP format, come up with a scenario and working diagnosis with 2 differential diagnosis'. 

SOAP FORMAT

SUBJECTIVE:

Questions you will ask

HPI

PMHx

FHx

SHx

Medications

ROS

OBJECTIVE:

Vitals with BMI

Constitutional

HEENT

Cardiac

Pulmo

GI

Musculoskeletal

Skin

GU - if relevant

• Always provide a very detailed physical exam, or description of what you want to elicit on your physical exam on the organ system involved in your chief complaint

ASSESSMENT:

Working Diagnosis

- provide ICD 10 codes

- provide rationales or pertinent positives and negatives that made you consider the diagnosis

Differential # 1

- diagnosis you cannot miss.

- rationale why it can't be missed

- provide ICD 10 code

Differential # 2

- what else could it be?

- rationale why you ruled it out

-provide ICD 10 Code

PLAN

• Diagnostics
• c, if not indicated state accordingly
• Health Education Plan
• Referral Plan - if not indicated, state accordingly
• Follow-up plan - indicate when patient needs to follow-up and what symptoms to watch out for
• Health promotion plan - age-specific health promotion recommendations not related to the case per USPTF
• National Standards of Care/ Short Narrative for working diagnosis