I-Human case study Babbitt- Migraine- 48 y/o Complete all elements of the case study (Patient history, physical exam, assessment, Tests, Diagnosis, Plan, Summary). Organize Key Findings 1. Assessment( contains six sections step) First categorize the problem identify in your history, physical exam, and vital signs sections) 2. Write a concise problem Statement(Chief Complaint) Start with a demographic description of your patient and chief complaint and most significant active problem. short description that includes the patient Chief complaints along with pivotal points relevant to selecting and prioritizing the differential diagnosis. Pivotal points are define as one of a pair of opposing descriptors use to compare/contrast diagnosis such as acute Vs chronic, persistent Vs intermittent. These pivotal point served provide the content or description of the chief complaints. 3. Select Problem categories- (Body system likely to be the source of the patient primary pathology). 4. Select Differential Diagnosis 5. Rank Differential Diagnosis(Leading Diagnosis,Alternative )- Finalize the ranking of your corrected Diagnosis. Rank the differential diagnosis. Indicate the leading(lead) or Alternative(Alt). Then indicate if the differential diagnosis represent a Must Not Miss(MNM) diagnosis or condition. 6. Select Test- (Select test that will help rule out each of the differential diagnosis for this case. A test may be associated with more then one diagnosis. First select the test then select the associated diagnosis. 7 . Diagnosis 8. Plan 9. Summary Organize Key Findings First choose one finding to be the (Most Significant Active Problem(MSAP) Then choose how each of the other findings relates to the (MSAP). You may arrange the list by relationship . Example Sore throat- MSAP Fever- related Headache-related Pharyngeal Erythema and Tonsillar exudate -related Infectious contact- per history- unknown infectious mono at age 15-resolved oral Contraceptive use- unrelated Family history of HTN- unrelated
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