Multiple Sclerosis

The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part.

The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan.

The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.

Patient Initials: Pt. Encounter Number:
Date: Age: Sex:
Allergies: Advanced Directives:
SUBJECTIVE
CC:
HPI: Describe the course of the patient’s illness:

Onset:

Location:

Duration:

Characteristics:

Aggravating Factors:

Relieving Factors:

Treatment:

Current Medications:
PMH

Medication Intolerances:

Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx:

Hospitalizations/Surgeries:

Family History:
Social History:
ROS
General Cardiovascular
Skin Respiratory
Eyes Gastrointestinal
Ears Genitourinary/Gynecological
Nose/Mouth/Throat Musculoskeletal
Breast Neurological
Heme/Lymph/Endo Psychiatric
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
PHYSICAL EXAMINATION
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests
Special Tests
Diagnosis
· Primary Diagnosis-

 Evidence for primary diagnosis should be documented in your Subjective and

Objective exams.

o Differential Diagnoses– Include three diagnoses

PLAN including education

o Plan:

 Further testing

 Medication

 Education

 Non-medication treatments

· Referrals

 Follow-up visits

References

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