Mixed Up Subjective and Objective Data Work Sheet: Case Study

Mixed up Subjective and Objective Data Work Sheet

A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother.  A.J. is a new patient, and this is her initial visit.  Her complaint is “left leg pain.”

Vitals: Temp:  37.0 C

HR: 88

RR: 16

BP: 110/72

Height: 5’ 6.”

Weight: 70.5 kg

1.  Read the rest of the case study below and then complete the blank Soap Note attached to the scenario.  Use only the information provided.

a. Decide what is pertinent and then place the components in the correct sections of subjective and objective components

b. Use appropriate abbreviations and concise terminology if appropriate

2. Provide a second Word document answering the following questions

a. What type of history will you obtain for this visit?

b. What additional history would you obtain from the family that is significant to A.J.’s situation

c. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided

d. For each of the following

i. Medical Diagnosis, 2 primary

1. Provide pathophysiology/Rationale/Plan

2. ICD 10 code

ii. Differential diagnosis, 3-5 Differentials

1. Provide pathophysiology/Rationale/plan

2. ICD 10 code

iii. Health maintenance/risk profile

iv. Pertinent positives

v. Pertinent negatives

e. Reference list

f. APA format

A.J. is a 15-year-old female, student.   A.J. participates competitively in Gymnastics.  She recently (3 days ago) had an injury to her left leg when she landed in an awkward position with a dismount from the uneven bars.  She has previously had an injury to her left knee, so the family put a brace on and started crutch use, but has not sought medical care.  The family knew that they had this upcoming appointment, so they chose to wait to seek care.  The left leg pain is isolated to the front lateral aspect of the left knee; It is not improved with their interventions, the mother states that she has given A.J. Motrin 600 mg 3-4 times a day since the injury. The injury is painful at night and worse when she is up at night with pain.  A.J. states that she is having trouble bending her knee when the brace is off.  She is frustrated with the injury and wants it better so that she can go back to practice; she has an important meet in 2 weeks.  A.J is currently a freshman in school (has just started back to school), previously her grades are A’s and B’s and struggles a bit in her algebra class but has utilized a tutor for help and is making progress in that class.

A.J. states that most of her friends are in the gym, she has a few friends at school, but since the gym takes so much of her time, it is hard to have time for friends in other settings.  A lot of her friends from middle school do not seem to have similar interests, 9^th grade was a new school for her and mom is hinting that it has been a hard transition.  Including this injury is making it hard for her to get around the campus between classes.

A.J. has no allergies

A.J. takes no medications

A.J. denies changes in her weight

A.J. eats a healthy diet, she has recently talked about becoming a vegetarian, no one in the family has food allergies, and they do not maintain a vegetarian diet.  Mom is concerned that she is not getting enough protein.  A.J. has not mentioned concerns with her weight but often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors.

A.J. Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs

A.J. denies sexual encounters, she likes boys, denies a boyfriend

A.J. participated in gymnastics five days a week for 1 to ½ hours a session, she likes to run as well but is recreational, no other clubs or interests

Previous left knee injury one year ago, no other broken bones to injuries

Birth history, term female, two other sibs (older) who are healthy.  Parents are married, and state that they are happy and financially comfortable.  She lives in a two story house, and her bedroom is upstairs, she is having challenges with navigating the steps with the crutches, one inside dog, no other animals.  Denies mental health concerns, but has been sadder the last couple of days and mom states short tempered with a recent injury.  No surgeries, hospitalizations or significant illness, trauma, or disabilities.  +yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11; mom states that immunizations were up to date.  Denies use of glasses or hearing aid, had her vision and hearing checked at PCP visit at age 11, has not sought primary care since that visit.  A.J. denies eye or vision issues, denies issues with her hearing or ear pain, denies a headache, denies nasal drainage, nose bleeds, or problems with smell or taste.  No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months. 

A.J. Denies issues with her heart, no palpitations or chest pain, no syncope, no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool.  No other concerns in her musculature other than her left knee.  

A.J. is currently having issues sleeping relating to pain, she is sleeping in her bed and has tried to elevate her left leg, denies problems with concentration at school or any memory issues.

Family denies any previous blood transfusions or use of chronic medications.

A.J. started her periods at age 12 years and had them monthly, used pads and had a period in the past month, no concerns verbalized with length or intensity of bleeding, no birth control and has never seen a GYN.

A.J. does not work outside the home

Parents: Dad has a high-stress job and hyper tension, on medications, Mom is a stay at home mom, +weight issues but overall no meds and healthy.  Siblings (one in college, girl, +weight issues and overall healthy), brother (senior in high school, is looking at going away to school, healthy).  Mom states no mental health concerns in the family, denies diabetes, exposure to communicable diseases, no recent travel outside of the US, no smokers, no stroke, lung disease, or asthma, no blood disorders, seizures, headache.  Paternal grandfather with hypertension

The concept with permission granted and appreciation per Dr. J Michaels.