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Primary Diagnosis and ICD-10 code: Also include any procedural codes.

Primary Diagnosis and ICD-10 code: Also include any procedural codes. 

3-5 Differential Diagnoses-
Why? What made you select each one as a DDX? How did you rule out? This would
be a good area to include references.


Additional laboratory and
diagnostic tests: May be necessary to establish or evaluate a condition. Some
tests, such as MRI, may require prior authorization from the patient’s
 insurance carrier. 


Consults: referrals to
specialists, therapists (physical, occupational), counselors, or other professionals.
If you are sending to hospital, what orders would you write for a direct admit?


Therapeutic modalities:
pharmacological and nonpharmacological management.


Health Promotion: Address risk
factors as appropriate. Consider age-appropriate preventive health screening.


Patient education: Explanations
and advice given to patient and family members.


Disposition/follow-up instructions: when the patient is to return sooner, and when to go
to another facility such as the emergency department, urgent care center,
specialist or therapist.


References (minimum of 3,
timely, that prove this plan follows current standard of care).”

L m  is a 13 years old
male child came to the clinic with his father ,with a complaint of testicular
pain on the left side of the groin region. The patient stated  that the pain started suddenly about two
hours ago when he was playing the basketball match.The pain is sharp
,persistent and increase when he walks or moves. He rated the pain 9 on the
pain scale from 0 to 10 .He is also experiencing nausea and vomiting once.
Patient has not taken any medication for the pain.

Caleb tachycardic 120bpm

Left testicles swollen and erythema


Pain to left testicles

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