Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints?

Hypertrophy of the breast / Soap Note 5 Ob /

It supports differential diagnosis. It contains evidence that the necessary steps were taken in order to accurately diagnose the patient’s condition. It mentions, for example, that the patient had a complete medical history taken and a physical exam performed. Lab tests were also ordered as necessary. In order to find the root cause of their symptoms, they also note that any relevant symptoms such as vomiting and abdominal pain were talked with patients.

There is evidence, as demonstrated by the notes taken during this visit, that there may be some information about which symptoms and systems are associated with what complaints. One example is that the note states that nausea may be due to gastro-intestinal distress, and muscle weakness might indicate possible renal problems. Both of these can guide any future testing. These factors show that the case was properly diagnosed.

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