A 67-year-old man is seen in the office with complaints of erectile dysfunction (ED). He says he has not had any desire for sex, and he has difficulty maintaining an erection.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including the inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
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
- Pharmacological Plan – indicate dosage and regimen, 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
