Problem
1) Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2) Analyze the objective portion of the note. List additional information that should be included in the documentation.
3) Is the assessment supported by the subjective and objective information? Why or why not?
4) Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
5) Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.