In Part 2 you might be … some additional history, exam or test findings. Using this information and the information in Part 1, answer the following questions:
What is your primary diagnosis for this patient? Tell the reader how you came to this conclusion using the information that you were … (i.e., CXR result, lab result). Interpret the results into your diagnosis decision (i.e., tell how this information helped you to narrow your differential to the one diagnosis that you chose). Identify the corresponding ICD-10 Code for the diagnosis.
Provide a treatment plan for this patient’s primary diagnosis which includes:a) Medication-all prescriptions and OTC medications should … written in RX format with an EBM to support:
Medication Name & Medication Strength
b) Any additional testing necessary for this particular diagnosis-typically done when you need more information to confirm a diagnosis or differentiate the diagnosis. Do not state all of the possibilities that are available. To assess your diagnostic reasoning skill, you will need to … decisive.
c) Patient education-self explanatory
d) Referral-self explanatory
e) F/U plan-include if and when the patient should follow-up *If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST … supported with an EBM argument as you did in Part 1.