This is to be a simple prelab case for students to get back into writing a SOAP note with a simple 1–2 Assessment and Plan (A/P) list. Essentially, this is a case (of the same patient) that happens before a hospitalization. The case (and video) that students will watch and write up in lab will be a postdischarge follow-up with more complications. This way, students will have some familiarity with the case.
Note: This video should be no more than 5 minutes in length, as students will only have <24 hours to write the SOAP note for lab the following day. Ancillary information will be available in a mock EHR for students to review.
Patient was diagnosed in the previous year with HF after an initial hospitalization. Since then, for the past 12 months at least, the patient has been relatively stable through adjusting medications. This visit is a 3-month f/u visit to review medications and see how patient is doing. In this case, patient is noted to be using inappropriate pain management therapy (NSAIDs) for his/her OA and needs to be instructed to use alternative therapy (APAP). This is up to the students to document on their own (and recognize in lab).
Scene 1—Prerounding with Student
Ok, so the next patient we are seeing today is relatively newer. John started coming here in the past year after being diagnosed with HF after a hospitalization last year. This is a 3-month follow-up visit. I assume you read over the past notes?
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Yep, so John is a 61-year-old man, past history including diabetes that seems relatively controlled, HTN, high cholesterol, CAD with a MI back in 2014 where he got 2 stents placed, and OA and a past knee replacement. The HF is most likely due to his past MI.
Overall, that’s a good summary of his past medical history. He’s a nice guy, and is easy to talk to. He has a hard time following instructions I’ve noticed, and I am led to believe he doesn’t always follow his diet appropriately.
For today, just concentrate on whether he’s taking the right medications and following good lifestyle modifications as needed, that’s been my big push for him lately.
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Understood. I’ll review his meds and other things he’s taking against what we have in the records and go over lifestyle changes. Aside from watching his fluids and salt intake anything else I should watch for?
Hmmmm. Well let’s see if he is exercising. He has diabetes but is only on metformin. Overall, I know he stated before his OA has been a ...