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48-year old male complains of severe epigastric pain that is worse after eating x 3 weeks. Symptoms are accompanied by nausea but patient denies vomiting or diarrhea at this time. Reports stools as “normal” in color and consistency.
For the case you have chosen:
1 – 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.
2 – In SOAP format, list: (Subjective, Objective, Assessment (FULL) and Plan of Treatment)
a) Pertinent positive and negative information
b) Differential and working diagnosis
c) 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.
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