A 58-year old male presents with a complaint of severe chest pain over the past
A 58-year old male presents with a complaint of severe chest pain over the past hour. He did not call 911 “because I don’t have the money for an ambulance.”
For the case you have chosen, post in the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
S- Subjective ( what the patient says)
O- Objective ( your assessment data)
A- Assessment ( Your working and differential diagnosis)
P- Plan (your next step-orders-education- USES Clincial Recommendations/References)