6904 Differential Diagnoses Worksheet
A 22 year- old hispanic male is seen in the student health clinic for a complaint of harsh
cough for 3 days. He stated he is tired, woke up sweaty and has no energy.
His vital signs are
taken by the medical assistant and are 100.8-92-26, 138/82.
Upon exam he is found slightly
short of breath, with cervical lymphadenopathy, yellow sputum, bilateral rales in lower
bases.
Develop a list of differential diagnoses using a
SOAP format
.
Subjective data
(S
)- what he states
Harsh coughx3 days
Tired
Diaphoresis
Fatigue
Objective data
(O)
- what is observed through exam
Elevated temp(100.8)
tachypnea
elevated BP
SOB
Cervical lymphadenopathy
Yellow sputum
Bilateral rales upon auscultation
What is your conclusion of possible medical diagnoses for this patient?
Assessment
(A)
-
List your differential diagnoses
1.
Bacterial pneumonia
2.
3.
4.
