04 Oct Read the rest of the case study attached and then
Read the rest of the case study attached and then complete the blank Soap Note attached to the scenario. Use only the information provided. Decide what is pertinent and then place the components in the correct sections of subjective and objective components Use appropriate abbreviations and concise terminology if appropriate If you are lacking pertinent information supply the questions that you would ask the patient (pretend you are completing the visit, how would you phrase the questions) Provide a second Word document answering the following questions What type of history will you obtain for this visit? What additional history would you obtain from the family that is significant to A.J.’s situation Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided Provided the following: · Medical Diagnosis (2) o ICD 10 code o Provide pathophysiology o Pertinent positives o Pertinent negatives · Differential diagnosis (3-5) · ICD 10 code o Provide pathophysiology (brief for each) o Pertinent positives o Pertinent negatives · Health maintenance/risk profile · Reference List APA format
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