A 52-year-old woman complains that she has been missing days ofwork almost every week, she states she is neglecting her family,and she is sleeping during the day but cannot sleep at night. Shedenies other health problems, medication, or environmentalallergies.
- Discuss what questions you would ask the patient, what physicalexam elements you would include, and what further testing you wouldwant to have performed.
- In SOAP format, list:
- Pertinent positive and negative information
- Differential and working diagnosis
- Treatment plan, including: pharmacotherapy with complementaryand OTC therapy, diagnostics (labs and testing), health educationand lifestyle changes, age-appropriate preventive care, andfollow-up to this visit.
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